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PRACTICAL SYNOPSIS 






®tMP<&K?S(DTO H»I1SI£&SI&S 9 



ACCORDING TO THE ARRANGEMENT OP 

DR. WILLAN, j, 



EXHIBITING A CONCISE VIEW OF THE DIAGNOSTIC 



SYMPTOMS AND THE METHOD OF TREATMENT- 



BY THOMAS BATEMAN, M.D.F.L-S. 

THYSICIAN TO THE PUBLIC DISPENSARY, AND TO THE FEVER INSTITUTION 



FIRST AMERICAN, FROM THE FOURTH LONDON EDITIO: 



N, 



PHILADELPHIA : 



PUBLISHED BY COLLINS & CROFT, 73, MARKET STREET, 

W. Brown, Printer, Prune Street 

ism 






IN EXC bfc 



JU " S 13X4 ( 



ADVERTISEMENT. 

This edition is a reprint of the last, with the exception 
of the concluding observations, relative to Syphilitic 
Eruptions, which have been altogether omitted. The 
further my experience has extended on the subject of 
these and the resembling Eruptions, the more com- 
plete has been my conviction, that any attempt to give 
a definite character of them is premature. Some cor- 
rection appears also to be required on the subject of 
Pompholyx, which, however, I am not yet enabled to 
make with sufficient accuracy. Although it is obvious 
that there is no such disease as the contagious fever, 
accompanied with Bullse, described by authors under 
the appellation of Pemphigus; yet some cases, which 
have been communicated to me, demonstrate the oc- 
casional concurrence of severe and even fatal fever 
with such an eruption, and therefore the necessity of 
modifying the definition and history of Pompholyx. 

T. B 

14, Bloomsbury Square, 
Dec. 12th, 1816. 



PREFACE 
TO THE FIRST EDITION 



To prevent any misapprehension in regard to the 
nature and object of this volume, it may be necessary 
to state, that it is not brought forward with any preten- 
sions to supply the deficiencies which have been left 
in the valuable treatise of Dr. Willan, or to be consi- 
dered as the completion of that original work. Its 
sole purpose is to present air abstract of the classifica- 
tion proposed by that respected author, together with 
a concise view of all the genera and species, which he 
intended that it should comprehend. The materials 
for the description of the first four Orders have been 
obtained principally from Dr. Willan 's publication, of 
which the first part of this Synopsis may be regarded 
as an abridgment: some additional facts, however, 
have been supplied from subsequent observation. 



PREFACE. 



The remainder of the matter has been derived partly 
from personal experience and research, but princi- 
pally from a constant intercourse with Dr. Willan, 
upon the subject of these diseases, during a period of 
ten years, while his colleague at the Public Dispen- 
sary, and from his own communications in his last 
illness, before he departed for Madeira, when he 
kindly undertook a cursory perusal of his unfinished 
MSS. for my information, during which I made notes 
relative to those points with which I was least ac- 
quainted. For it was, in fact, his wish, that the pro- 
fession should possess a sketch of the whole of his 
arrangement, even when the completion of his own 
treatise, though distant, was not without hope. Were 
I capable of following my learned preceptor through 
the literary and historical researches which enriched 
his publication, it would be altogether incompatible 
with my plan. I have, however, deemed it advisable 
to introduce into notes some brief illustrations and 
references, which, without interrupting the practical 
details, may satisfy the reader that the principles of 
the classification and nomenclature were not adopted 
without the sanction of reason and authority. 



PREFACE. VI! 

I am far from maintaining that this arrangement of 
cutaneous diseases is altogether free from material 
imperfections; (for what artificial arrangement of 
natural objects has yet been devised, to which imper- 
fections may not be imputed?) but I apprehend it will 
be impossible to study it carefully and practically, 
without deriving benefit from the exercise. I am 
aware, indeed, that there are many individuals, pro- 
fessing themselves to be practical men, who affect a 
contempt for all nosological disquisitions, and deem 
the discussions relating to nomenclature, in particular, 
very idle and frivolous, or, at the best, a sort of lite- 
rary amusement, which is not conducive, in the small- 
est degree, to the improvement of the medical art. 
But this I conceive to be a mistaken view of the sub- 
ject, originating perhaps from indolence, or from a 
want of habitual precision in the use of language. 
The inferences of slight and superficial observation 
may, indeed, be detailed without recourse to a very 
definite vocabulary; for, where little discrimination is 
exercised, very little nicety can be requisite in regard 
to the import of the language employed. But it is 
not by such means that the boundaries of science are 
extended. 



Vlll PREFACE. 

Among the manifest advantages of a copious and 
definite nomenclature, may be mentioned, in the first 
place, the necessity which it demands of an accurate 
investigation of phsenomena, or, in other words, the 
habitual analytic turn which it tends to give to our 
inquiries, and therefore the general improvement of 
the talent of observation which it must ultimately 
produce. Secondly, it contributes to facilitate the 
means of discrimination, by multiplying, as it were, 
the instruments of distinct conception; for, from a 
deficiency of terms we are apt to think, and even to 
observe indistinctly. But, above all, a definite nomen- 
clature supplies us with the means of communicating, 
with precision, the information which we acquire, and 
therefore contributes directly to the advancement of 
knowledge, or at least removes an otherwise insur- 
mountable impediment to its progress. 

In this view, such a nomenclature, as far as regards 
the diseases of the skin, is obviously a great desidera- 
tum. For, while the language taught us by the fathers 
of medicine, relative to all other classes of diseases, is 
clear and intelligible, the names of cutaneous disorders 
have been used in various acceptations, and without 



PREFACE. ;X 

much discrimination, from the days of Hippocrates, 
and still more vaguely since the revival of learning in 
modern times. From that period, indeed, the dis- 
eases of the skin have been generally designated by 
some few terms of universal import, which therefore 
carried no import at all. Hence the words leprosy, 
scurvy, herpes, scabies, dartres, and some other ap- 
pellations, have become so indefinite, as to be merely 
synonyms of cutaneous disease. Even the more sci- 
entific inquirers, whose knowledge of diseases was 
not always equal to their learning, or whose learning 
fell short of their pathological skill, have interpreted 
the generic and specific appellations of the ancients in 
various senses. They have not only differed, for in- 
stance, in their acceptation of general terms, such as 
of the words pustule, phlyctcena, exanthema, erythema, 
phyma, phlzyacium, &c. ; but the particular appella- 
tions lichen, psora, herpes, impetigo, porrigo, scabies, 
and many others, have been arbitrarily appropriated 
to very different genera of disease. The practical 
errors, which must necessarily have resulted from such 
a confusion in the use of terms, are very numerous, as 
every one must be satisfied, who has attempted to 
b 



A PREFACE. 

study the subject in books. It may be sufficient to 
allude to the gross misapplication of the remedies of 
the petechial or sea scurvy, which have been pre- 
scribed for the cure of inflammatory, scaly, and pus- 
tular diseases, merely because the epithet, scorbutic. 
has been vaguely assigned to them all; and to specify 
the single instance of the administration of tincture of 
cantharides in the scaly lepra, on the recommenda- 
tion of Dr. Mead, who, however, seems to have spoken 
of the tubercular elephantiasis, or the non-squamous 
leuce; although it would be very difficult to ascertain 
his meaning. 

Most of the writers who have composed express 
treatises on cutaneous diseases, in modern times, have 
implicitly adopted the nomenclature of the ancients, 
without attempting to render it more definite, or to 
improve upon the diagnosis which they had pointed 
out. The essays of Mercurialis, Hafenreffer, Bona- 
cursius, and Turner, were written after this manner; 
and even Lorry, in his able and elegant work, does 
not step far out of the ancient path. About the year 
1 780, however, an elaborate classification of the dis- 
eases of the skin was published by Prof. Plenck, of 
the university of Buda; and subsequently to the com- 



PREFACE. Xi 

mencement of Dr. Willan's publication, a sort of ar- 
rangement has been proposed, in the splendid and 
pompous performance of M. Alibert, which however 
is altogether destitute of method. 

The arrangement of Plenck. is founded upon the 
same principles as that of Dr. Willan, namely, upon 
the external appearances of the eruptions : but, in 
filling up the scheme, he has deviated widely from 
the strict laws of classification, which naturalists 
have established. Nine of his fourteen classes very 
nearly correspond with the eight orders of Dr. Wil- 
lan* These are, 1. Maculae; 2. Pustulae; 3. Vesi- 
culaa, 4. Bulla?; 5. Papulae; 6. Crustae; 7. Squamae; 
8. Callositates; and 9. Excrescentiae. But the five 
remaining classes comprise, 10. Ulcera; 11. Vul- 
nera; 12. Insecta cutanea; 13. Morbi Unguium; and 
14. Morbi Capillorum, which are less judiciously de- 
vised. But such a classification must fail to answer 
its end, because it requires the different stages of 

* It seems probable, indeed, that Dr. Willan was indebted to 
this work of Professor Plenck for the groundwork of his clas- 
sification ; since his definitions, as well as his terhns, accord 
accurately with those of the Hungarian nosologist- 



Xll PREFACE. 

the same disease to be considered as so many dis- 
tinct maladies, and to be arranged in several classes . 
For example, the Crustae and the Ulcera cutanea 
are equally the result of Pustules, Vesicles, and Bul- 
la?, and sometimes even of Scales: hence, while 
Smallpox and Scabies are arranged among the Pus- 
tules, and Lepra (by which he understands Elephan- 
tiasis) among the Papulae, the Crusts, which succeed 
them, are all brought together as species of one ge- 
nus, in the class of Crustse. In like manner, parti- 
cular symptoms are classed as distinct genera: thus 
the " Rugositas" and the " Rhagades" of the same 
Elephantiasis are found in the classes of Squamae 
and Ulcera respectively. In short, this Elephan- 
tiasis is divided into no less than four genera, and its 
parts arranged under four different classes; — an error, 
which renders the purposes of the classification al- 
most nugatory. 

M. Alibert, with loud pretensions to superior skill, 
and much vaunting of the services which he has 
rendered this department of medicine, has, in fact, 
contributed nothing to the elucidation of the obscurity 
in which it is veiled, The merit of his publication 



PREFACE. XU1 

belongs principally to the artists, whom he has had 
the good fortune to employ. For he has adopted the 
ancient confusion of terms, without a single defini- 
tion to fix their acceptation; and he has not scrupled 
to borrow the nomenclature of the vulgar, in its most 
vague and indeterminate sense. He has, moreover, 
thrown together his genera, without any attention to 
their affinity or dissimilarity, making an arbitrary 
whole of disjointed parts. Thus his arrangement 
commences with " Les Teignes" (Porrigo,) which are 
followed by " Les Pliques" (Plica or Trichiasis,) and 
by " Les Dartres" (which seems to be equivalent to 
our vulgar and indefinite term Scurvy,) — and he then 
passes to the discolorations, called " Ephelides," to 
some eruptions, which he chooses to call " Can- 
croides," but which are not intelligibly described, — 
to the comprehensive Lepra, — to Framboesia, — and 
to Ichthyosis. 

But the total defect of discrimination and of method 
is still more obvious in M. Aliberfs distribution of 
the species. The Dartres, for instance, are said to 
be of seven kinds, — furfuraceous, scaly, crustaceous, 
phagedenic, pustular, vesicular, and erythemoid; so 
tfiat, in fact, the appellation has an universal fitness 



XIV PREFACE. 

to almost every form of cutaneous disease: it includes 
at least the Pityriasis, Psoriasis, Lepra, Impetigo, 
Ecthyma, Herpes, Acne, Sycosis, Lupus, and Ery- 
thema, of this classification. In like manner, the Le- 
pra includes some forms of the scaly disease properly 
so called, together with Leuce or Vitiligo, the tuber- 
cular Elephantiasis, and the Barbadoes leg. Thus he 
unites, under the same generic name, diseases which 
have no affinity with each other. 

From these gross errors the classification of Dr. 
Willan appears to be entirely free; and the imperfec- 
tions, which confessedly belong to it, are probably 
inseparable from the nature of the subject. The truth 
is, that the various genera of cutaneous disease, as 
characterized by their external appearances, do not 
differ in the same essential degree, in which the diseases 
of organs of various structure differ from each other. 
The same exciting cause will produce different kinds of 
cutaneous disorder, in different individuals: thus, cer- 
tain substances, which suddenly derange the organs 
of digestion, sometimes produce Urticaria, some- 
times Erythema and Roseola, and sometimes even 
lepra and psoriasis; yet each of these shall retain its 



PREFACE. XV 

specific character, and follow its peculiar course: thus 
also certain external irritants will, in one case, excite 
the pustules of impetigo, and, in another, the vesi- 
cles of eczema. Again, the diseases which commence 
with one generic character, are liable occasionally to 
assume another, in the course of their progress: — thus, 
some of the papular eruptions become scaly, and still 
more frequently pustular, if their duration be long 
protracted; the lichen simplex and circumscriptus, for 
instance, sometimes pass into psoriasis; the lichen 
agrius and prurigo formicans are occasionally convert- 
ed into impetigo; and the prurigo mitis is changed to 
scabies. Moreover, it frequently happens, that the 
characteristic forms of eruptive diseases are not pure 
and unmixed, but with the more predominant appear- 
ance there is combined a partial eruption of another 
character: thus, with the papular strophulus, with the 
rashes of measles and scarlet fever, and with the pus- 
tular impetigo and scabies, there is occasionally an in- 
termixture of lymphatic vesicles. And lastly, the na- 
tural progress of many eruptions is to assume a con- 
siderable variety of aspect; so that it is only at some 
particular period of their course thatfoieir character is 



XVI PREFACE. 

to be unequivocally decided. Thus in the commence- 
ment of scabies papuliformis and lymphatica, the erup- 
tion is of a vesicular character, although its final ten- 
dency is to the pustular form: and, on the contrary, 
in all the varieties of herpes, the general character of 
the eruption is purely vesicular; yet, as it advances in 
its progress, the inclosed lymph of the vesicles acquires 
a considerable degree of opacity, and might be deem- 
ed purulent by cursory observers. In like manner, 
the original pustular character of some of the forms 
of porrigo is frequently lost in the accumulating crusts, 
the confluent ulcerations, and the furfuraceous exfo- 
liations, which ensue, and which conceal its true na- 
ture from those who have not seen, and are unac- 
quainted with, the whole course of its advancement. 

These circumstances constitute a series of natural 
impediments to every attempt at a methodical arrange- 
ment of cutaneous diseases. But it is more philoso- 
phical, as well as practically useful, to compromise 
these difficulties, by retaining in the same station the 
different appearances of a disease, in its different stages 
and circumstances, when our knowledge of the causes 
and remedies, as well as of the natural progress and 



PREFACE. XVI! 

termination of it, is sufficient to establish its identity,- — 
than to separate the varying symptoms of the same dis- 
order, and to distribute the disjecta membra, not only 
under different genera, but into different classes of the 
system, after the manner of Prof. Plenck. Such was 
the method adopted by Dr. Willan; and, although it 
may sometimes diminish the facility of referring indi- 
vidual appearances to their place in the nosological 
system; yet it greatly simplifies the classification, as 
well as the practical indications to which it conducts us. 
If, then, the adoption of the arrangement and no- 
menclature, of which a synopsis is here given, should 
lead to more clear and definite views of the various 
forms of cutaneous disease, and should enable practi- 
tioners to write and converse respecting them with 
perspicuity, by fixing the meaning of the terms which 
they employ, we may consider this as an important ob- 
ject gained: and it will at length, perhaps, be found, 
that, for the successful treatment of these diseases, the 
discovery of new medicines is less necessary than a 
discriminate appropriation of those which we already 



I am fully aware that it is very difficult to convey 
c 



XV111 PREFACE. 

by words, used in an acceptation that is not familiar, 
distinct notions of many of the minute changes of ap- 
pearance in the skin; and that one great deficiency, 
which Dr. Willan's larger work was calculated to sup- 
ply, by means of the engravings which accompanied 
it, will be left unprovided for by this synopsis. Per- 
haps, however, this defect will be partially obviated by 
the plate prefixed to this volume, in which I have en- 
deavoured to convey an idea of the fundamental prin- 
ciples of the classification, as well as to designate the 
characters of some of the more remarkable genera of 
cutaneous disease. 

T. B. 

14, Bloomsbury Square* 
May 25, 1813. 



XIX 



EXPLANATION OF THE PLATE. 



The eight compartments of the plate exhibit the eight forms 
of cutaneous eruptions, and illustrate also some of the genera and 
species. 

Fig. 1. represents five varieties of papula, as they are seen in 
(a) Strophulus confertus, (b) Lichen simplex, (c) Lichen pilaris, 
(d) Lichen lividus, and (e) Prurigo mitis. 

Fig. 2. shows the scales and circular patches of Lepra vulgaris. 

Fig. 3. exhibits two forms of exanthemata or rashes, viz. (f) the 
measles, and (g) the febrile nettle-rash. 

Fig. 4. shows the bullce of Pompholyx diutinus, in different stages 
of their progress. 

Fig. 5. illustrates the four forms of pustules, distinguished in Def. 
5 ; namely, the phlyzacia, as they appear in (h) Ecthyma vulgare, 
and in (i) Scabies purulenta upon the hands ; — the psydracia, as 
they arise in (k) Impetigo, and afterwards form a scab ; — the 
achores, (1) of Porrigo scutulata, on the scalp ; — and the favi (m) 
as they appear on the scalp and other parts. 

Fig. 6. contains three genera of vesicles; namely, patches of (n) 
Herpes zoster, and (o) Herpes phlyctaenodes; (p) miliary vesicles; 
and (q) the vaccine vesicle. 

Fig. 7. exhibits different forms of tubercles; as in (r) Acne 
punctata, and (s) Acne indurata; in (t) Sycosis: and in (v) Mol- 
luscum. 

Fig. 8. contains specimens of Macula; viz. (w) a Ncevus com- 
pared to the stain of red wine; (x) a spider Naevus; and (y) a 
mole. 



XX 



DEFINITIONS 



1. Papula (Pimple); a very small and acuminate* 
elevation of the cuticle, with an inflamed base, very sel- 
dom containing a fluid, or suppurating, and commonly 
terminating in scurf.* 

2. Squama (Scale); a lamina of morbid cuticle, hard., 
thickened, whitish, and opake. Scales, when they in- 
crease into irregular layers, are denominated crusts. 

3. Exanthema (Rash); superficial red patches, va- 
riously figured, and diffused irregularly over the body ? 
leaving interstices of a natural colour, and terminating in 
cuticular exfoliations. 

* The term, papula, has been used in various acceptations by 
the older writers, but the nosologists have nearly agreed in re- 
stricting it to the sense here adopted. Sauvages defines it," phy- 
ma parvulum, desquamari solitum." (Nosol. Meth. class. l.Sy- 
nops. ord. ii. 6. See also Linnaei Gen. Morbor. class, xi. ord. 4.) In 
this sense also Celsus seems to have understood the term, although 
he uses it generally : for when he calls it a disease, in which " the 
skin is made rough and red by very minute pustules," he means 
obviously dry papulae; as by the word pustula he understands 
every elevation of the skin, including even wheals. (De Med. lib, 
v. cap. 28. § 15 and 1 8.) See below, p. 147. note. 



DEFINITIONS. XXI 

4. Bulla (Bleb)\ a large portion of the cuticle de- 
tached from the skin by the interposition of a transpa- 
rent watery fluid. 

5. Pustula (Pustule)] an elevation of the cuticle, 
with an inflamed base, containing pus. 

Four varieties of pustules are denominated in this 
arrangement as follows: 

a. Phlyzacium; a pustule commonly of a large size, 
raised on a hard circular base, of a vivid red colour, 
and succeeded by a thick, hard, dark-coloured scab.* 

b. Psydracium; a small pustule, often irregularly cir- 
cumscribed, producing but a slight elevation of the 
cflticle, and terminating in a laminated scab.f Many 

* The derivation of this term, " enro m <p^va>, <p*vg&>, sive 
QXve-G-u, quod servere significat, et ebullire" (Gorraei Def. Med.) 
Would render it sufficiently appropriate to elevated and inflamed 
pustules, if we had not possessed also the interpretation left by 
Celsus; "pXv&Ktov autem paulo durior pustula est, subalbida, 
acuta ; ex qua quod exprimitur, homidum est. Ex pustulis vero 
nonnunquam etiam ulcuscula fiunt, aut aridioi'a, aut humidiora s 
et modo tantum cum prurigine, modo etiam cum inflammatione 
aut dolore ; exitque aut pus, aut sanies, aut utrumque. Maxi- 
meque id evenit in aetate puerili raro in medio corpore ; saepe in 
eminentibus partibus." (De Medicina, liv. v. cap. 28. § 15,) — 
See also Ecthyma, below, p. 185. 

f As the Phlyzacia were denominated from the heat of the 
eruption, so the Psydracia received their appellation from the 
opposite quality, " quasi tyvxpet, vtyxxtcc, id est, frigid e seu frigefac- 
tae guttula" says Gonaeub. — The psydracia are enumerated 
among the eruptions peculiar to the head by Alexander and Paul, 
and some other Greek writers; but Galen and others mention 



XX11 DEFINITIONS. 

of the psydracia usually appear together, and become 
confluent; and, after the discharge of pus, they pour 
out a thin watery humour, which frequently forms an 
irregular incrustation. 

c. Achor; and 

d. Favus. These two pustules are considered by the 
majority of writers from the Greeks downwards, as va- 
rieties of the same genus, differing chiefly in magnitude .* 
The AcJwr may be defined, a small acuminated pustule, 
containing a straw-coloured matter, which has the ap- 
pearance and nearly the consistence of strained honey, 
and succeeded by a thin brown or yellowish scab. The 
Favus, or *«/><•», is larger than the AcJtor, flatter, and not 
acuminated, and contains a more viscid matter; its base, 
which is often irregular, is slightly inflamed; and it is 
succeeded by a yellow, semitransparent, and sometimes 
cellular scab, like a honey-comb; whence it has obtained 
its name. 

6. Vesicula (Vesicle); a small orbicular elevation of 
the cuticle, containing lymph, which is sometimes clear 
and colourless, but often opaque, and whitish or pearl- 
coloured. It is succeeded either by scurf, or by a la- 
minated scab. 

them as common to other parts of the body. (See Alex. Trail. 
Op. lib. i. cap. 5. Paul. jEgin. lib. iii. cap. 1. Actuarius, lib. vi- 
cap. 2.) See also Impetigo, below, p. 148. 

* See Aetius, tetrab. ii. serm. ii, cap. 68. — Alex. Trail, lib. i> 
cap. 8 & 9. — Paul. jEsin. De Re Med. lib. iii. cap. 3. — Oribas. De 
Loc. Affect, lib. iv. cap. 12. See also Porrigo, below, p. 162. 



DEFINITIONS. XXlll 

7. Tuberculum (Tubercle)] a small, hard, superfi- 
cial tumour, circumscribed and permanent, or suppurat- 
ing partially. 

8. Macula (Spot)] a permanent discoloration of 
some portion of the skin, often with a change of its 
texture. 

The following terms are used in their ordinary ac- 
ceptation; viz. 

9. Wheal; a rounded or longitudinal elevation of the 
cuticle, with a white summit, but not permanent, not 
containing a fluid, nor tending to suppuration. 

10. Furfur (Scurf )\ small exfoliations of the cuti- 
cle, which occur after slight inflammation of the skin, a 
new cuticle being formed underneath during the exfo- 
liation. 

11. Scab; a hard substance, covering superficial ul- 
cerations, and formed by a concretion of the fluid dis- 
charged from them. 

12. Stigma; a minute red speck in the skin, without 
any elevation of the cuticle. When Stigmata coalesce, 
and assume a dark-red or livid colour, they are termed 
Petechias. 



XXIV 

The Diseases of the Skin were arranged by Dr. Willan in eight 
orders, according to their external forms above defined, as in 
the following table. 



frder I. 






Page 






PORRIGO 


162 


PAPULiE. 




ECTHYMA 


185 


STROPHULUS 


Page 


VARIOLA 


193 
194 


LICHEN 


6 


SCABIES 


PRURIGO 


14 


VI. 




II. 




VESICUL^. 




SQXJAMiE. 




VARICELLA 


212 


LEPRA 


25 


VACCINIA 


220 


PSORIASIS 


36 


HERPES 


227 


PITYRIASIS 


45 


RUPIA 


247 


ICHTHYOSIS 


49 


MILIARIA 


249 






ECZEMA 


257 


III. 




APHTHA 


268 


EXANTHEMATA 










VII. 




RUBEOLA 

SCARLATINA 


57 

70 


TUBERCULA 




URTICARIA 


89 


PHYMA 


278 


ROSEOLA 


97 


VERRUCA 


279 


PURPURA 


104 


MOLLUSCUM 


ibid. 


ERYTHEMA 


119 


VITILIGO 


281 






ACNE 


284 


IV. 




SYCOSIS 


300 


BULLAE. 




LUPUS 


304 


ERYSIPELAS 


127 


ELEPHANTIASIS 


306 


PEMPHIGUS 


138 


FRAMB03SIA 


%22 


POMPHOLYX 


142 


VIII. 




V. 




MACULE. 




PUSTULES. 




EPHELIS 


331 


IMPETIGO 


148 


N;£VUS, SPILUS, ETC. 


334 



PRACTICAL SYNOPSIS 



CUTANEOUS DISEASES. 



Order L 
PAPULA. 

PAPULiE, or Pimples, (Def. I.) appear to originate in 
an inflammation of the papillse of the skin, by which these 
are enlarged, elevated, and indurated, and made to as- 
sume more or less of a red colour. Sometimes even a 
slight effusion of lymph takes place, which gives a vesi- 
cular appearance to several of the papulae; but the fluid 
is re-absorbed without breaking the cuticle, and they 
terminate for the most part in scurf. 

The varieties of papulous eruptions are comprehended 
in this arrangement under three genera; namely, Stro- 
phulus, Lichen, and Prurigo. 



I. STROPHULUS. 
This genus comprises several papular affections, pe- 
culiar to infants, which are known by the common ap- 
pellations of red gum, tooth-eruption, &c. They arise, 
in consequence of the extreme vascularity and irritability 



2 PAPULJE: 

of the skin at that period of life, when the constitution 
is accidentally disturbed by irritation, either in the ali- 
mentary canal, the gums, or other parts. As they are 
not, however, very important objects of medical practice, 
but interesting only from their occasional resemblance 
to some of the exanthemata, I shall not dwell upon them 
at any length. The following varieties are mentioned 
by Dr. Willan. 

1. Strophulus intertinctus. (Plate I.) the red gum or 
gown, occurs chiefly within the two first months after 
birth, and is characterized by papula3 of a vivid red 
colour, situated most commonly on the cheeks, fore- 
arms, and back of the hands, but sometimes universally 
diffused. They are usually distinct from each other; 
but are intermixed with red dots, or stigmata, (Def. 12.) 
and often with larger red patches, which have no ele- 
vation. Occasionally a few small vesicles appear on 
the hands and feet; but these soon desiccate, without 
breaking. 

This eruption is often obviously connected with a 
weak, irritable state of the alimentary canal, and conse- 
quent indigestion; whence it is frequently preceded by- 
sickness of stomach, and sometimes by diarrhoea. But 
in its ordinary mild form it is not inconsistent with good 
health, and requires little medical treatment. Daily 
ablutions with tepid water, which remove sordes and 
promote an equable perspiration, are beneficial; and a 
proper attention should be enforced both to the kind and 



STROPHULUS. 3 

quantity of the aliment, and to the regularity of exercise 
afforded to the child. The cold bath, or even exposure 
to a stream of cold air, should be avoided during the 
occurrence of this eruption; and if, in consequence 
of want of caution in this respect, the eruption shall 
have disappeared, and internal disorder have ensued, a 
warm bath affords the most speedy relief: — some slight 
cordial, as a few drops of the spiritus ammonias compo- 
site internally, and the stimulus of a blister exter- 
nally, have also been found beneficial under these cir- 
cumstances* 

2. Strophulus albidus (Plate II.) is merely a vari- 
ety of the preceding species, and is occasionally inter- 
mixed with it; the papulae consisting of minute, hard, 
whitish specks, a little elevated, and sometimes sur- 
rounded by a slight redness, and appearing chiefly on 
the face, neck, and breast. 

3. Strophulus confertus, (Plate III. Fig. 1.) which 
is sometimes called the rank red gum, and the tooth- 
rash, is distinguished principally by the more extensive 
crop of papulae which appears. These are chiefly seat- 

* See Underwood on the Diseases of Children, vol. i. p. 79. 
5th edit, and Armstrong on the same subject, p. 84. These 
alternations of internal and superficial disorder, though not so 
frequently seen under modern management as under that of the 
older physicians, take place occasionally in Strophulus, as well as 
in the measles, and some other exanthemata. In such cases, di- 
arrhoea, tormina, sickness, and sometimes a tendency to syncope 
•r convulsions, ensue. 



PAPULA: 

eel on the cheeks and forehead, when they occur about 
the fourth or fifth month, and are smaller, more crowded, 
and less vivid in their colour, than in the first species. 
But in children seven or eight months old, they 
appear in large irregular patches, on the outside of the 
hands, arms, and shoulders, and are hard and close set. 
so as to give to the whole surface a high red colour. 
In about a fortnight they begin to fade and exfoliate, and 
gradually disappear. 

Sometimes, though rarely, a variety of the S. confer - 
tus appears on the legs, spreading upwards even to the 
loins and navel, producing a general redness of the cuti- 
cle, (not unlike intertrigo,) which cracks and separates 
in large pieces, occasioning much distress to the child. 
It is liable to recur at short intervals, for the space oi 
two or three months. 

The S. confertus requires no specific medical treat- 
ment, as it appears to be one of the numerous symptoms 
of irritation arising from dentition, and recedes soon 
after the cutting of the first teeth.* It can only be 
alleviated by the general treatment proper for the state 

*Dr. Bisset, a physician of the old school, but a man of observa- 
tion, notices a circumstance respecting children affected with 
these eruptions, which I think I have seen confirmed in a few 
cases. After stating that " some children are more or less affei ted 
with it till they have got all their first teeth, in spite of every en- 
deavour to repress it, and after that period it recedes spontaneous- 
ly ;" he adds, " but in that case they are apt to have carious teeth 
after the eruption disappears." See his Med. Essays and Obs. 
§ xix. p. 274. 



STROPHULUS. & 

of teething, with great attention to cleanliness, and fre- 
quent tepid ablution with milk and water. 

4. Strophulus volaticus (Plate III. Fig. 2.) is not 
a frequent complaint. It is characterized by small 
circular patches, or clusters of papulae, arising and 
exfoliating successively on different parts of the body, 
of a high red colour, and sometimes attended with 
slight feverishness. Each patch turns brown in about 
four days, and begins to exfoliate; and the whole series 
terminates in three or four weeks. 

This eruption is usually connected with disorder of 
the stomach and bowels, and is alleviated by gentle 
laxatives; after which the decoction of cinchona, or a 
slight chalybeate,* is serviceable. No external applica- 
tion is necessary. 

5. Strophulus candidus (Plate III. Fig. 3.) is dis- 
tinguished by papulae of a larger size than those of the 
foregoing species, having no inflammation round their 
base, and a smooth and shining surface; whence they ap- 
pear to be of a lighter colour than the adjoining cuticle. 
They are most frequently seen on the loins, shoulders, 

* I shall take this opportunity of recommending to the attention 
of practitioners a chalybeate medicine, particularly adapted, from 
its tasteless quality, to the palates of children, and possessed of 
more efficacy than the vinum ferri ; I mean a watery solution of 
the tartrite of iron, lately introduced by an able and intelligent 
chemist, Mr. R. Pnillips. See his Experimental Examination of the 
Pharm. Londinensis, 1811. Its qualities have been well stater! by 
Dr. Birkbeck, in the London Medical Review, No. xix. July 1812, 



6 PAPULAE: 

and upper part of the arms; but I have observed them 
also on the face and neck, when the S. confertus occu- 
pied the fore-arms: after continuing hard and elevated 
for about a week, they gradually disappear. This variety 
of Strophulus commonly succeeds some of the acute 
diseases, to which infants about a year old are liable. It 
has occurred also on the arms, when the face was occu- 
pied with porrigo larvalis: and in one case it appeared 
on the arms, thighs, and neck, at the age of three years 
and a half, during the cutting of the double teeth. 



II. LICHEN. 

The original acceptation of the term Lichen is not 
distinctly ascertained from the writings of Hippocrates, 
and therefore it has been variously interpreted by suc- 
ceeding writers.* The majority have deemed it syno- 
nymous with the impetigo of the Latins: but, as Foes. 
De Gorter, and other able commentators, have remark- 
ed, the impetigo described by the highest Roman au- 
thority, Celsus, is a very different disease; while the 
papula of the same author seems to accord more accu- 

* Hippocrates classes the Aeiywes with prurigo, psora, lepra, 
and alphos, without particularizing their characteristic forms. See 
his Tlpoppynxov, lib. ii. and his book Tie pi TlxlHav, where he considers 
them as blemishes rather than diseases. It would seem, indeed, 
that the Greek writers after him looked upon the prurigo, lichen- 
psora, and lepra, as progressive degrees of the same affection; 
the first being a simple itching, — the second, itching combined 
with roughness of the sfcin, — the third, itching with branny exfo- 
ations, — and the last, itching with actual scales. 



LICHEN. 7 

rately with the lichen of Hippocrates * Whence Dr. 
Willan decided on affixing the appellation to a papular 
affection of the following character: 

" An extensive eruption of papulae, affecting adults, 
connected with internal disorder, usually terminating in 
scurf, recurrent, not contagious." 

The varieties of this eruption are seven. 

1. The Lichen simplex (Plate IV. Fig. 1.) is an 
eruption of red papulae, first appearing on the face or 
on the arms, and extending, in the course of three or 
four days, to the trunk and lower limbs. It is preceded 
for a few days by slight febrile irritation, which com- 
monly ceases when the eruption appears. This is ac- 
companied with an unpleasant sensation of tingling, 
especially in the night: it continues nearly stationary 
about a week, when its colour begins to fade, and the 
skin soon exhibits numerous scurfy exfoliations, which 

* See Foes. CEconom. Hippocr. — De Gorter, Medicina Hip- 
pocrat. aph. xx. lib. iii. The latter observes, respecting this 
aphorism, " In hoc loco, Hippocr. per Leichenas intelligit talem 
cutis faedationem, in qua summa cutis pustulis siccis admodum 
prurientibus exasperatur. — Sed quia humor totus fere volatilis 
est, non relinquit squamas ut lepra, neque furfures ut psora, sed 
siccam et asperam pustulosam cutim." It is to be recollected that 
fiustula, among the ancients, signified any elevation of the cuticle ; 
and therefore pustulse siccse are papulae. If the lichen, then, 
be viewed in its concluding stage, when it exhibits a slight fur- 
furaceous roughness, it may be said to have some affinity with the 
scaly diseases mentioned above; and, in fact, it sometimes termi- 
nates in psoriasis. See Aetius, tetrab. ii. serm. iv. cap. 16. — Ac- 
iuar. lib. ii. cap. 1 1.— Celsus de Medicina, lib. v. cap. 28. 



5 PAPULA: 

remain longest about the flexures of the joints. The 
duration of the complaint varies considerably, however, 
from ten days to three weeks. 

The disorder is subject to variety also in other 
respects. The papulse on the face, for instance, are 
large and rounded, and some of them form into small 
tubercles, resembling those of acne: on the breast 
and extremities they are more acuminated; and on the 
hands they are sometimes obscurely vesicular. In some 
cases, the eruption is partial, affecting the face, neck, or 
arms only; in some, it appears and disappears repeated- 
ly, without leaving any scurf; and in others, successive 
eruptions and exfoliations prolong the complaint for two 
or three months. 

The L. simplex is liable to return every summer in 
some individuals of irritable constitution. It appears 
occasionally in those who are subject to severe head- 
ache and pains in the stomach, as a sort of crisis to 
these complaints, which are immediately relieved. It is 
also sometimes a sequela of acute fevers.* 

This species of lichen is often mistaken for measles, 
scarlatina, and other exanthemata. But a strict atten- 
tion to Definitions 1 and 3, and to the course of the 
symptoms, will enable the observer to avoid such errors. 
It is sometimes also mistaken for scabies (itch), from 
which it is not always so easily distinguished-! 

* See Lorry de Morbis Cutaneis, cap. iii. p. 215. 

t Set Scabies. — Prof. Lorry has stated the principal points of 
diagnosis with accuracy. Speaking of lichen, under the appella- 
tion of " Papulae," he says, " Primo a scabie differunt, quod pa- 



LICHEN. 9 

2. Lichen pilaris (Plate V. Fig. 1.) is merely a 
modification of the preceding species, the papulae ap- 
pearing only at the roots of the hairs of the skin. Like 
the former, it often alternates with complaints of the 
head or stomach, in irritable habits. It is not unfre- 
quently connected with that derangement of these or- 
gans which is induced by intemperance in the use of 
spirits. The great irritability of the skin is manifest, 
from the facility with which the papulae are enlarged 
into temporary wheals by strong friction, which the 
itching and tingling compel the patient to resort to. 

3. Lichen circumscriptus (Plate V. Fig. 3.) is cha- 
racterized by clusters or patches of papulae, which have 
a well defined margin, and are of an irregularly circular 
form.* Some of them are stationary for a week or two, 
and disappear; but others extend gradually, by new pa- 
pulated borders, into large figured forms, which coalesce. 
As the borders extend, the central areae become even, 

pulse illae vulgo magis confertse sint et elatiores; 2do, quod rubi- 
cundse magis et minus ari,dae sint; 3tio, quod saepe sanatis febribus 
superveniant ; 4to, quod latiores sint, et ssepius recidivam pa- 
tiantur quam vera et legitima scabies ; 5to, quod in furfur abeant 
notabile ; 6to, demum quod remediis sanentur a scabiei curatione 
alienis." Loc. cit. 

* This variety of Lichen was not noticed in the first edition of 
the Order of Papulae, published by Dr. Willan. It is the first of 
the two species of papula described by Celsus : — " Medium habet 
pauxillum levius: tarde serpit; idque vitium maxime rotundum 
incipit, eaque ratione in orbem procedit." De Medicina, lib. v. cap, 
38. See also Ingrassiasde Tumor, prjet. Naturam, tract. 1. sap. 1. 



10 PAPULAE: 

but continue slightly red and scurfy. Sometimes, be- 
fore the scurf is removed, a new crop of papulae arises, 
terminating like the former in exfoliations; and by these 
new eruptions the complaint is prolonged for several 
weeks. It may be excited either by internal or external 
causes of irritation. In adults it is occasionally produced 
by vaccination, and may be deemed a proof of the full 
affection of the constitution by the virus. 

Little medicinal treatment is necessary for these spe- 
cies of Lichen. It is sufficient that patients avoid heat- 
ing themselves by much exercise or by stimulants, and 
take a light diet, with diluent drinks, and a gentle laxa- 
tive occasionally. The diluted sulphuric acid is a grate- 
ful tonic to the stomach during the period of exfoliation 
or a light chalybeate may be taken with advantage at 
the same period. All strong external applications are 
improper, especially preparations of mercury and of 
sulphur, which produce severe irritation. The ancients 
recommended that the parts should be besmeared every 
morning with saliva; and some demulcent lotion, as a 
substitute for this uncleanly expedient, prepared with 
the white of egg, or emulsion of almonds, will relieve 
the painful sensations of the patient. Lotions of lime- 
water, or of liquor ammonias acetatis, much diluted, oc- 
casionally also afford relief. 

4. The Lichen agrius (Plate IV. Fig. 2.) is ushered 
in by febrile symptoms, which are commonly relieved 
on the appearance of the papulous eruption. The pa- 
pulae occur in large patches, are of a high red colour, 



LICHEN. 1 1 

and have a degree of inflammation diffused round them 
to a considerable extent. They are accompanied by 
itching, heat, and a painful tingling, which are augment- 
ed to a sensation of smarting and scalding by the heat 
of the bed, washing with soap, drinking wine, or using 
violent exercise. The symptoms undergo a daily in- 
crease and remission: for they are all greatly diminished 
in the morning, and recur after dinner. Some small 
vesicles, filled with a straw-coloured fluid, are occasion- 
ally intermixed with the papulae; but they are not per- 
manent. 

The duration of the L. agrius is various: sometimes 
it continues for several weeks; and, in most instances^ 
the eruption appears and disappears repeatedly before 
the disease is removed. In both these cases, the cuticle 
of the parts affected becomes harsh, thickened, chappy, 
and exquisitely painful on being rubbed or handled. 
After repeated attacks, indeed, it is liable to terminate 
in a chronic pustular disease, the impetigo* This ten- 
dency, and the diffuse redness connecting the papulae, 

* Celsus describes his second species of papula under the ap- 
pellation of oiypia, or f era; and has also pointed out its tendency to 
pass into impetigo: — " Difficilius sanescit; nisi sublata est, in im- 
petiginem vertitur." (loc. cit.) His successors, the Greek writers, 
have also applied the same epithet to the severe form of Lichen. 
Galen speaks of Lichen simplex et ferus, «ar^ss ««< «y/><«s ; (Isa- 
goge, cap. 13. See also Paul. iEgin. de Re Med. lib. iv. cap. 3; 
ano Oribas. ad Eunap. lib. iii. cap. 57.) and Aetius of rough and of 
inflamed Lichens, ??*%£& *#/ (pteypoimvTss, (tetrab. iv. serm. L 
cap. 134.) which appear to express the same varieties. 



12 PAPULA: 

distinguish the L. agrius from the preceding species, 
which occasionally pass into psoriasis, as observed by 
the ancients. 

The L. agrius is sometimes repelled by exposure to 
cold, upon which an acute febrile disorder ensues, with 
vomiting, headache, ant pains in the bowels, and con- 
tinues for several days. Women are more liable to this 
species of Lichen than men, particularly after suffering 
long continued fatigue, with watching and anxiety: it 
sometimes occurs in spirit-drinkers. 

The treatment of this Lichen consists in administer- 
ing, at first, some moderate laxatives, mercurial or saline, 
and afterwards, for some time, the diluted sulphuric 
acid, three times a day, in the infusion of roses, or de- 
coction of cinchona. A simple cooling unguent, as 
the rose pomatum, or litharge plaster softened with oil 
of almonds,* allays the troublesome heat or itching. 
All stimulating applications are, still more than in the 
preceding species, both painful and injurious. 

5. Lichen lividus (Plate V. Fig. 2.) is distinguished 
by the dark red or livid hue of its papulee, which ap- 
pear chiefly on the extremities, and without any accom- 
panying symptoms of fever. The papula? are more 

* The formula of a mild ointment of this sort is used at the 
public dispensary, by Mr. Pearson's recommendation. & Em- 
plast. plumbi ?ij, ceue flavae § ss, olei amygdal. dulc. §iss. Em- 
plastro cum cera liquefacto adde oleum, dein agita misturam 
donee penitus rcfrixerit, 



LICHEN. IS 

permanent, however, than in the foregoing varieties : 
and, after their desiccation, the disorder is liable to be 
prolonged for many weeks by a fresh eruption. 

Its affinity with the purpura is evinced by the inter- 
mixture of petechias with the papulae ; and by the simi- 
larity of the origin and requisite treatment of the two 
diseases* 

6. Lichen tropicus, or " prickly heat," as it is 
called in the West Indies, is a hot and painful form of 
Lichen, peculiar to tropical climates, and has been de- 
scribed at great length by most of the writers on the 
diseases of those regions ; to whose publications I shall 
therefore refer the reader, f 

7. There is scarcely any limit to the varieties of 
these papular affections : but I have observed one form, 
which is so uniform in its character as to be entitled to 
notice here. It may be called Lichen urticatus ; as 
its first appearance is in irregular, inflamed wheals, so 
closely resembling the spots excited by the bites of bugs 
or gnats, as almost to deceive the observer. The in- 
flammation, however, subsides in a day or two, leaving 
small, elevated, itching papulae. While the first wheals 

* See below, Order iii. Gen. 5. 

t See Hillary on the Climate and Diseases of Barbadoes, p. 3, 
Introd. ; Moseley on the Diseases of Tropical Climates, p. 20 ; 
Cleghorn on the Diseases of Minorca, chap. 4 ; Clark on the 
Diseases of Seamen in Long Voyages, vol. i. p. 34 j Bontius de 
Medicina Indorum, cap. 18. 



14 PAPULA : 

are thus terminating, new ones continue to appear in 
succession, until the whole body and limbs are spotted 
with papula?, which become here and there confluent, 
in small patches. This eruption is peculiar to chil- 
dren : it commences, in some cases, soon after birth, 
and sometimes later, and continues with great obstinacy 
for many months. It is commonly ascribed by parents 
to vaccination. Both the wheals and the papulae are 
acr ompanied with intense itching, which is exceedingly 
severe in the night, occasioning an almost total inter- 
ruption of sleep, and considerable loss of flesh. 

Frequent tepid bathing, light covering, especially in 
bed, with the use of small doses of sulphur, or the 
hydrargyrus sulphuratus niger, internally, appear to 
relieve the symptoms. The skin will not bear stimu- 
lation, and is irritated even by a bath of too high tem- 
perature. When it has occurred in feeble and ema- 
ciated children, I have seen it effectually relieved by 
chalybeate medicines, as the vinum ferri, or the so- 
lution of the tartrite before mentioned. This combi- 
nation of inflamed papulae, with intense itching, unites 
the characters of the Lichen and prurigo ; an union, 
which, it must be allowed, is likewise not unfrequent 
in young adult persons. 



III. PRURIGO. 
The characteristic symptoms of this genus are, a se- 
vere itching, accompanied by an eruption of papula? of 
nearly the same colour with the adjoining cuticle. It af- 



PRURIGO. 15 

tects the whole surface of the skin, under three varieties 
of form, as well as some parts of the body locally. 

1. Prurigo mitis (Plate VI. Fig. 1.) is accompanied 
by soft and smooth papulae, somewhat larger and less 
acuminated than those of lichen, and seldom appear- 
ing red or inflamed, except from violent friction. Hence 
an inattentive observer may overlook the papulae alto- 
gether :* more especially as a number of small thin 
black scabs are here and there conspicuous, and arrest 
his attention. These originate from the concretion of 
a little watery humour, mixed with blood, which oozes 
out, when the tops of the papulae are removed, by the 
violent rubbing or scratching which the severe itching 
demands. This constant friction sometimes also pro- 
duces inflamed pustules ; which are merely incidental^ 
however, when they occur at an early period of the 
complaint. The itching is much aggravated both by 
sudden exposure to the air, and by heat ; whence it is 
particularly distressing when the patient undresses him- 
self, and often prevents sleep for several hours after he 
gets into bed. 

This eruption mostly affects young persons, and 
commonly occurs in the spring or beginning of sum- 
mer. It is relieved after a little time by a steady per- 
severance in the use of the tepid bath, or of regular 
ablution with warm water, although at first this stimu- 

* Pruritus enormes non semper densae confertaeque papulae af- 
ferunt ; paucae vix aspectu notandae occurrunt, quae hominem con- 
vellant. Lorry de Morb. Cutan. cap. iii. art. i. par. 2. 



16 PAPULA : 

lus slightly aggravates the eruption.* The internal 
use of sulphur, alone, or combined with soda or a little 
nitre, continued for a short time, contributes to lessen 
the cutaneous irritation ; and may be followed by tho 
exhibition of the mineral acids. Under these remedies, 
the disorder gradually disappears : but if the washing 
be neglected, and a system of uncleanliness in the apparel 
be pursued, it will continue during several months, and 
may ultimately terminate in the contagious scabies. 

2. Prurigo formicans. (Plate VI. Fig. 2.) This 
affection differs materially from the preceding, in the 
obstinacy and severity of its symptoms, although its 
appearances are not very dissimilar. The itching ac- 
companying it is incessant, and is combined with vari- 
ous other painful sensations ; as of insects creeping 
over and stinging the skin, or of hot needles piercing 
it. On undressing, or standing before a fire, but above 
all on becoming warm in bed, these sensations are 
greatly aggravated; and friction not only produces red- 
ness, but raises large wheals, which, however, presentl} 
subside. The little black scabs, which form upon the 
abraded papulse, are seen spotting the whole surface, 
while the colourless papulce are often so minute as nearly 
to escape observation. 

* After recommending a bath of moderate temperature, Lorry 
observes, " Nee mirandum, si inter balneorum usum plures pa- 
pulae prodeant. Etenim laxatis vasis, ad cutem omnia deferri 
aequum est. Sed nulla inde ratio est, cur minus balneis fidamus.' ? 
Loc. cit. 



PRURIGO. 17 

This prurigo occurs in adults, and is not peculiar to 
any season. It affects the whole of the trunk and limbs, 
except the feet and palms of the hands; but is most copi- 
ous in those parts over which the dress is tightest. Its 
duration is generally considerable, sometimes extending, 
with short intermissions, to two years or more. It is 
never, however, converted, like the preceding species, 
into the itch, nor becomes contagious; but it occasionally 
ends in impetigo. 

The causes of the P. formicans are not always ob- 
vious. In some instances it is distinctly connected with 
disorder in the stomach; being preceded by sickness, 
gastrodynia, and headache: and in others, it appears 
to be the result of particular modes of diet, especially 
of the use of much stimulant animal food, in hot 
weather, with a free potation of wine, spirits, and fer- 
mented liquors, and excess in the use of condiments, 
pickles, and vinegar.* On the other hand, it is often 
observed in persons of lean habit, and sallow com- 

* I have known several instances of the immediate influence of 
the acetous acid upon the skin, especially in summer, exciting 
heat and tingling very soonijafter it was swallowed ; and, in persons 
of peculiar cutaneous irritability, leaving more permanent effects. 
Dr. Withering asks, " Who has not observed the full scarlet flush 
upon the face after eating herrings, or vinegar, after drinking ace- 
tous beer or cycler ?" Treatise on Scarlet Fever, p. 62. The uni- 
versal recommendation of vegetable acids and crude herbs, indeed, 
in these states of cutaneous irritation, in consequence of a misap- 
plication of the term scorbutic, is in opposition to the dictates of 
sound observation. 

G 



IS PAPULiK: 

plexion, and in those who are affected with visceral 
obstructions, or reduced by fatigue, watching, and low 
diet. 

The treatment of P. formicans must necessarily be 
varied according to the circumstances just stated; but 
it is not readily alleviated either by internal or external 
medicines. Where it appears to be connected with a 
state of general debility, or with some disorder of the 
abdominal viscera, the first object will be to remove 
these conditions by proper diet and exercise, together 
with medicines adapted to the nature of the case. 
Where the stomach is obviously disordered, the regu- 
lation of the diet is of material importance, especially 
as to the omission of those prejudicial articles above 
mentioned, and the substitution of a light digestible 
food, and of whey, milk, ass's milk, butter-milk, &,c. as 
beverage. This regulation of the diet, indeed, is in all 
cases of the disease to be recommended, though there 
may be no apparent internal complaint from which it 
originates. For, in these cases, medicine alone is often 
extremely inert. 

Combined with proper diet, the use of washed sul- 
phur with the carbonate of soda, internally, has much 
alleviated the painful state of sensation, and shortened 
the duration of the disorder: and where the habit was 
enfeebled, the decoctions of sarsaparilla, cinchona, ser- 
pentaria, and other tonic vegetables, have proved essen- 
tially serviceable. I have seen considerable benefit de- 
rived from the internal use of the oxygenated muriatic 



PRURIGO. 1& 

acid, in this and the former species of prurigo, both 
the eruption and the itching yielding during its exhi- 
bition. It may be taken in doses of a drachm, and in- 
creased gradually to three times this quantity, in water 
or any agreeable vehicle. Strong purgatives, or a course 
of purgation, appear to be injurious; antimonials and 
mercurials are useless; and active sudorifics aggravate 
the complaint. 

In respect to external remedies frequent ablution 
with warm water, by removing the irritation of sordes 
and softening the skin, contributes most materially to 
the patient's relief. A bath of the native or artificial 
sulphureous waters is still more efficacious in relieving 
the itching; and sea bathing has also occasionally 
removed the disorder. In general the application of 
ointments, or of lotions containing sulphur, hellebore, 
mercury, zinc, lime-water, &c. is productive of little 
benefit: I have sometimes, however, found a speedy 
alleviation produced by a diluted wash of the liquor 
ammoniae acetatis, or of spirit, or by a combination of 
these, varied in strength according to the irritability of 
the skin. 

3. Prurigo senilis. (Plate VI. Fig. 3.) The frequent 
occurrence of prurigo in old age, and the difficulty of 
curing it, have been the subject of universal observation.* 

* See Hippoc. Aph. lib. iii. § iii. 31, where, among other dis- 
eases of old age, he mentions tyrpoi m evy^esTa? ohov. — -Its obstinacy 
has been particularly noticed by the later Greeks. « Pruritum in 



20 PAPULiE: 

The sensation of itching, in the prurigo of that period 
of life, is as intolerable and more permanent than in the 
P. formicans: and the appearances which it exhibit? 
are very similar, except that the papulae are for the 
most part larger. The comfort of the remainder of life 
is sometimes entirely destroyed by the occurrence of this 
disease. 

A warm bath affords the most effectual alleviation of 
the patient's distress, but its influence is temporary. 
The disorder seems to be connected with a languid 
state of the constitution in general, and of the cutaneous 
circulation in particular: hence the sulphureous waters 
of Harrowgate, employed both internally and externally 
at the same time, afford on the whole the most decided 
benefit. A warm sea-water bath has also been found 
serviceable. Sometimes stimulant lotions, containing 
the oxy muriate of mercury, the liquor ammonias ace- 
tads, or alcohol, are productive of great relief, and occa- 
sionally render the condition of the patient compara- 
tively comfortable, or even remove the disease.* When 

scnectute contingentem perfecte sanare non datur, verum subscrip- 
ts mitigare potes." Paul. JEgin. de Re Med. lib. iv. cap. 4. Ac- 
tual". Meth. Med. lib. ii. cap. 11. — See also Sennert. Pract. lib. v. 
p. iii. § i. cap. 8. — Mercurialis de Morb. curand. cap. 3. Heber- 
den, Comment, cap. 76. 

* Dr. Heberden lays it down as an axiom, that stimulants are 
commonly beneficial in diseases of the skin accompanied by itch- 
ing. " Quod attinet ad remedia extrinsecus admovenda, illud se- 
dulo tenendum est, acriora plerumque convenire, ubi pruritus est; 
sin dolor fuerit, lenia esse adhibenda," See. (Comment, cap. 23.) 



PRURIGO. 21 

the surface is not much abraded, the oxymuriate will 
be borne to the extent of two grains to the ounce of an 
aqueous or weak spirituous vehicle; but it is generally 
necessary to begin with a much smaller proportion. 

This mineral salt is likewise useful in destroying the 
pediculi, which are not unfrequently generated, when 
the prurigo senilis is present. Where the skin is not 
abraded by scratching, the oil of turpentine, much dilut- 
ed with oil of almonds, may be applied, with more decid- 
ed effect, for the destruction of these insects* 

This is true, perhaps, as far as it regards the unbroken or 
papulated skin : but itching often accompanies chops and rha- 
gades, vesicular and even pustular diseases in a state of excoria- 
tion, and the irritable state of the surface left by the exfoliations 
of some of the scaly eruptions ; under all which circumstances, 
this is an erroneous rule of practice, as I have had many opportu- 
nities of witnessing. 

* The pertinacity with which these loathsome insects often con- 
tinue to infest the skin, in spite of every application that is resort- 
ed to, is surprising ; but, as Dr. Willan has justly observed, the 
marvellous histories of fatality occasioned by lice, in the persons of 
Pherecydes, Antiochus, Herod, Sec. are probably ascribable to mis- 
take ; the writers having confounded other insects, or their larvse, 
with pediculi. Numerous instances are recorded of the generation 
of maggots, i. e. the larvse of different species of fly (Musca) and 
even of other winged insects, not only in the internal cavities of the 
human body, but in external sores and excoriations.' (For several 
examples of this kind I beg leave to refer to a paper of my own in 
the Edin. Med. and Surg. Journal for Jan. 1811, p. 41, and in the 
new Cyclopaedia of Dr. Rees, Art. Insects.) In warm climates, 
indeed, these insects are so abundant about the persons of the sick, 
that the utmost care is requisite to prevent the generation of larvse 
from the ova, which they depositj not only in superficial wounds. 



%% PAPULA. 

The local pruriginous affections above mentioned 
have scarcely any affinity with the prurigo just describ- 
ed, except in the itching which accompanies them, 
not being in general papular diseases. The P. pre- 
puiii is occasioned by an altered or augmented secre- 
tion about the carona glandis, and is cured by frequent 
simple ablution of the parts, or by a saturnine lotion. 
The P. jwbis arises solely from the presence of mor- 
piones, or pediculi pubis, which are readily destroyed 
by mercurial ointment. And the P. uretkralis is com- 
monly sympathetic of some disease about the neck of 
the bladder, or of calculi in that organ: in women, how- 
ever, it sometimes occurs without any manifest cause, 
and is removable by the use of bougies, as recommended 
by Dr. Hunter. 

but in the nostrils, mouth, gums, Sec. Dr. Lempriere has recorded 
the case of an officer's lady, who had gone through an acute fever, 
but in whom " these maggots were produced, which burrowed and 
found their way by the nose through the os cribriforme, into the 
cavity of the cranium, and afterwards into the brain itself, to 
which she owed her death." (Obs. on the Diseases of the Army 
in Jamaica, vol. ii. p. 182.) The worms which were generated in 
the patches of lepra, observed by Prof. Murray, proved to be lar- 
vae of the common house-fly. " Incredibile fere est," he says, 
" quanta muscarum domesticarum copia continuo ad lectum advo- 
larent, aegrumque suctu suo torquerent, ut in clamorem usque 
nonnunquam erumperet." (De Vermibus in Lepra obviis Obs. 
Auct. J. A. Murray, Gbtt. 1769, p. 25.) In all such cases, the 
disease appears to have afforded only a nidus for the ova of these 
domestic insects, and to have been in no other way connected 
with their existence, either as cause or effect. See Scabies. 



PRURIGO. 2$ 

Two forms of local prurigo, namely, P. podicis, and 
pudendi muliebris, are more frequently the objects of 
medical treatment. Independently of ascarides, or 
haemorrhoids, which sometimes occasion a trouble- 
some itching about the sphincter ani, the P. podicis 
occurs in sedentary persons, and those of advanced age, 
in connexion with an altered secretion from the part, 
and sometimes with constitutional debility. This com- 
plaint is apt to extend to the scrotum, especially in old 
men, which becomes of a brown colour, and sometimes 
thick and scaly. The itching, in these cases, is ex- 
tremely severe, especially at night, and often deprives 
the patient of a considerable portion of his sleep. A 
troublesome prurigo scroti is also occasionally pro- 
duced by friction, from violent exercise, in hot weather; 
and sometimes it originates from the irritation of asca- 
rides in the rectum. 

Lotions, whether warm or cold, with preparations 
of lead, zinc, lime-water, &c. have little efficacy in 
these affections. Those made with vinegar, or the ace- 
tate of ammonia, are productive of a temporary relief. 
But the mercurial ointments, especially the unguentum 
hydrargyri nitratis diluted, are the most successful appli- 
cations. — Internally, small doses of calomel, with an an- 
timonial, such as the pilula hydrargyri submuriatis of the 
New Pharmacopoeia, seem to be advantageous in cor- 
recting the morbid secretion; and the vegetable or mine- 
ral tonics should be administered in enfeebled habits. 
Great temperance should be inculcated in the case of 



U PAPULA: 

P. podicis; since stimulant diet invariably aggravates 
the complaint. 

The P. pudendi muliebns is somewhat analogous to 
the preceding, but is occasionally a much more severe 
complaint. It is sometimes connected with ascarides 
In the rectum, and sometimes with leucorrhoaa; but is 
most violent when it occurs soon after the cessation 
of the catamenia. The itching about the labia and os 
vaginas is constant and almost intolerable, demanding 
incessantly the relief of friction and of cooling applica- 
tions, so as to compel the patients to shun society, and 
even sometimes to excite at the same time a degree of 
nymphomania. 

This condition is generally accompanied by some 
fulness and redness of the parts, sometimes by inflamed 
papula?, and sometimes by aphthae. Saturnine and 
saline lotions, lime-water, lime-water with calomel, 
vinegar, and oily liniments prepared with soda or pot- 
ass, are beneficial, especially in the milder cases: but 
the most active remedy is a solution of the oxymuriate 
of mercury in lime-water, in the proportion of two 
grains, or a little more, to the ounce. As in the cases 
before mentioned, however, the presence of rhagades 
or excoriations will require palliation, before it can be 
employed. 



26 

Order II 
SQUAJMLE... 

SCALY DISEASES. 

Those opaque and thickened laminae of the Cuticle^ 
which are called Scales (Def. 2.) are commonly pro- 
duced by some degree of inflammation of the true skin, 
over which they are formed; but occasionally, as in the 
slighter forms of pityriasis, the cuticle alone, or with 
the rete mucosum, appears to be in a morbid condition, 
If the definition be carefully attended to, scales will not 
be confounded with the scabs succeeding confluent pus- 
tules and vesicles, or superficial ulcerations. 

The four genera of scaly diseases are, Lepra, Pso- 
riasis, Pityriasis, and Ichthyosis. 



I. LEPRA. 

The term Lepra is here appropriated solely to the 
Lejwosy of the Cheeks, as described by the more accu- 
rate of those writers. It is characterized by "scaly 
patches, of different sizes, but having always nearly a 
circular form."* 

* The confusion which has every where prevailed in the use of 
the terms Lepra and Lefirosy, seems to have originated principally 
with the translators of the Arabian writers after the revival of 
learning. The Greeks agreed in appropriating the appellation of 



26 SQJJAMJE: 

1. Lepra vulgaris* (Plate VII.) the ordinary species 
of the disease in this country, commences with small, 
round, reddish, and shining elevations of the skin, at 
first smooth, but within a day or two exhibiting thin 
white scales on their tops. These gradually, sometimes 
rapidly, dilate to the size of half-a-crown, still retaining 
their oval or circular form, and are covered with shining 
scales, and encircled by a dry, red, and slightly elevated 
border. In some cases, these scales accumulate, so as 
to form thick prominent crusts. If the scales or crusts 

tex-px to a scaly eruption (as its elymology dictated) ; most of them 
deemed it the highest degree of scaliness, exceeding in this re- 
spect the lichenes, psora, and alphos ; and those who were most 
minute in their description stated, that " it affects the skin deeply, 
in circular patches, at the same time throwing off scales like those 
of large fishes." (See Paul. jEgin. de Re Med. lib. iv. cap. 2; — ■ 
and Actuarius de Meth. Med. lib. ii. cap. 1 1 : — also A'etius, tetrab. 
iv. serm. i. cap. 134; and Galen. Isagoge.) This was sufficiently 
clear : but those who translated the works of the Arabians int» 
Latin, fell into the extraordinary mistake of applying the Greek 
term to a tubercular disease, which had been actually described 
by the Greeks under the appellation of elephantiasis; and they 
applied the barbarous term morfihza, together with scabies and 
impetigo, to the scaly diseases of the Greeks above enumerated. 
Whence their followers, who detected the error, spoke of the 
Lepra Arabum as well as the Lepra Graecorum ; while the less 
accurate confounded every foul cutaneous disease under the term 
leprosy. The Arabians themselves do not employ the word Lepra; 
but have described these different diseases under appropriate ap- 
pellations. See Elephantiasis below. 

* The " Dartre furfuracee arrondie" of Alibert, represented m 
plate 12 of his large work, livraison III, 



LEPRA. 27 

are removed, the skin appears red and shining, being 
very smooth, and free from the euticular lines in the 
beginning, but marked, in the advanced stages, with 
long deep lines and reticulations, not always coinciding 
with those of the adjoining surface. 

The Lepra most commonly commences on the ex- 
tremities, where the bones lie nearest to the surface; 
especially below the elbow and the knee, and usually on 
both arms, or both legs, at the same time. From these 
points it gradually extends, by the formation of new and 
distinct patches, along the arms or thighs, to the breast 
and shoulders, and to the loins and sides of the abdo- 
men. In several cases, I have observed the eruption 
most copious and most permanent round the whole 
lower belly. The hands also become affected, and in 
many cases the hairy scalp; but the face is seldom the 
seat of large patches, although some scaliness occasion- 
ally appears about the outer angles of the eyes, and on 
the forehead and temples, extending from the roots of 
the hair. In the more severe cases, the nails of the 
fingers and toes are often much thickened, and become 
opaque and of a dirty yellowish hue, and are incurvated 
at the extremities: their surface is also irregular, from 
deep longitudinal furrows, or elevated ridges. 

When the eruption of Lepra is moderate in degree 
and extent, it is not attended with any uneasy sensa- 
tions, except a slight degree of itching when the patient 
is heated by exercise, or becomes warm in bed; and a 
little occasional tingling in certain states of the atmo- 



28 SQUAMA: 

sphere* When it is generally diffused, however, and 
there is a considerable degree of inflammation in the 
skin, it is accompanied with extreme soreness, pain, 
and stiffness; which I have sometimes seen so great as 
to render the motions of the joints impracticable, and 
to confine the patient to bed. Yet even under these 
circumstances, there is no constitutional disturbance; 
and if no medicine be employed, the disease of the skin 
may continue for months, or even years, without any 
material derangement of the system. 

It is not easy to point out the causes of this disease, 
which appear, indeed, to be veiy various; for it is one 
of the most common affections of the skin, at least in 
this metropolis, and occurs at all periods, and under 
every circumstance of life.f It is certainly not com- 
municable by contagion, nor does it appear to origi- 
nate from confinement to certain kinds of diet, such as 
fish, dried or salted meats, &c; since it is not ende- 



* Hippocrates remarks that 6ome Le/ira itch before rain : lib. 

fief) Xv/A6)\>. 

t It is difficult, therefore, to account for the opinion expressed 
by the late Dr. Heberden, respecting the extreme rarity of Lepra 
in this country. " De vero scorbuto et lepra, nihil habeo quod 
dicam, cum alter rarissimus est in urbibus, altera in Anglia pene 
ignota ; unde factum est ut hos morbos nunquam curaverim." 
(Comment, cap. 23.) And still more difficult to explain the state- 
ment of Dr. Cullen, whose definition of Lepra will include both 
the dry and humid tetters (psoriasis and impetigo) with the pro- 
per scaly Lepra; but who nevertheless affirms that he had never 
seen the disease, Nosol. Meth. class, iii. gen. 88, note. 



LEPRA. 29 

mic in districts where these are habitually used, and 
occurs frequently where they are almost unknown. 
But, like some other cutaneous affections of a more 
transient character, it is certainly produced occasionally 
by the influence of particular articles of food and drink, 
which operate through the idiosyncrasy of individuals. 
I have met with one gentleman, in whom spices or 
alcohol speedily produce it. The original attack in 
him occurred after eating some hot soup, containing 
spice, the first spoonful of which excited a violent 
tingling over the whole head, which was followed by 
the leprous eruption, which soon extended to the limbs. 
In another case, in a young gentleman of nineteen, the 
disease commenced after taking copious draughts of 
cream : and vinegar, oatmeal, and other species of 
food, to which it has been ascribed, have probably 
given rise to it occasionally : but these are all anoma- 
lies, and are only referrible to peculiar idiosyncrasy* 
In some cases it has commenced after violent and con- 
tinued exercise, by which the body had been much 
heated and fatigued. 

Dr. Willan has imputed the origin of Lepra to cold 
and moisture, and to certain dry sordes on the skin. 
It has seldom occurred to me, however, to witness the 



* Some poisonous substances taken into the stomach have pro- 
duced an eruption of Lepra. The poison of copper is stated to have 
speedily excited it in several persons at the same time, in one of 
whom it continued for a month, but disappeared in the others in 
about ten days. See Med. Facts and Obs. vol. iii. p. 61. 



30 SQPAAlffi . 

disease in bakers, laboratory-men, and others who 
work among dry powdery substances ; while I have 
observed a considerable number of cases in young 
ladies, and in persons of both sexes in respectable ranks 
ef life, by whom every attention to cleanliness was 
scrupulously paid. Where cold and moisture have 
excited the eruption of Lepra, the predisposition to it 
must have been peculiarly great. On the whole, the 
causes of this disease are involved in much obscurity. 
There is obviously an hereditary predisposition to it in 
some individuals. 

2. Lepra alphohles* (Plate VIII. Fig. 1.) This is a 
less severe form of the disease than the preceding. It 
differs chiefly in the small size of the patches, which sel- 

* The Greeks have described the Alphas as a milder disease, 
being more superficial, and less rough, than the Lepra: (see Galen, 
de Sympt. Caus. lib. iii. — Aet. tetrab. iv. serm. i. cap. 134 :) and 
the description of it given by Celsus accords with the appearances 
of the L. alphoides above stated. " A\<p<K vocatur, ubi color albus 
est, fere subasper, et non continuus, ut quxdam quasi gutlae dis- 
persae videantur. Interdum etiam latius, et cum quibusdam in- 
termissionibus, serpit." (De Medicina, lib. v. cap. 28.) Celsus 
no where employs the term Lepra. 

This scaly Al/ihos, which was deemed by Hippocrates a blemish 
rather than a disease (Tlepi UxSm, sect. 15,) was distinguished from 
another white affection of the skin, the leuce, which was not scaly, 
but consisted of smooth, shining patches, on which the hairs turned 
white and silky, and the skin itself, and even the muscular flesh 
underneath, lost its sensibility. The leuce was a disease of an in- 
curable nature. (Hipp. Ifya^Vix. lib. ii.) Celsus. although point- 



LEPRA. 31 

dom extend beyond the diameter of a few lines, or be- 
come confluent, — in the minuteness and greater white- 
ness of the scales, — and in its limitation to the extre- 
mities. This variety of Lepra is most common in chil- 
dren. It is tedious and difficult of cure, like the former, 
and requires similar treatment. 

It would be superfluous to enumerate the catalogue 
of useless medicines, which have been recommended 
from ancient times for the cure of Lepra : I shall, there- 
fore, confine my attention to those of the beneficial 
agency of which I can speak from experience. It is 
necessary to premise, however, that there is no one 
remedy, nor any invariable plan of treatment, which 
will succeed in Lepra, under all the circumstances of 
its appearance in different instances ; and that great 
errors are committed by prescribing for the name of 

ing out this distinction, includes the leuce and the alphos under 
the same generic title, Vitiligo, (loc. cit.) 

It may be remarked that the Arabians distinguished these two 
affections by different generic appellations ; calling the alphos, 
Albohak, and the leuce, Albaras^ with the epithet white. Their 
translators have called the former morfihcsa, and included the leuce 
and elephantiasis under the appellation of Lefira. By retaining 
these distinctions in recollection, the accounts of the older writers 
may be read, while the confusion arising from their misapplication 
of names may be avoided. 

It appears probable that the leuce was the leprosy of the Jews^ 
described in Leviticus, chap. xiii. See Greg. Horstii Obs. Med- 
lib. vii. p. 330. — Leon. Fuchsii Paradox, lib. ii. cap. 16. — Th. 
Campanellse Ord. Medic, lib. vi. cap. 23. — Hensler, Von Abend- 
landischen Aussatz, p. 341. 



U SQUAMLE : 

the disease. The circumstances to which I allude 
more particularly are the different degrees of cutane- 
ous excitement, or inflammatory action, which accom- 
pany the disease in different habits ; and which, if care- 
fully attended to, afford an important guide to the 
most successful application of remedies. 

In the less irritable conditions of the leprous eruption, 
in which no inflammatory tendency appears, such as the 
L. alphoides frequently, and the L. vulgaris occasionally, 
exhibits, a gently stimulant mode of treatment, at least 
externally, is requisite ; though in all cases of Lepra the 
diet should be light and moderate, and heating liquors 
should be avoided ; especially malt liquors and spirits ; 
for every indulgence in these points will be felt in the 
aggravation of the symptoms. A frequent Use of the 
warm bath, with which a moderate degree of friction 
may be combined, contributes to remove the scales, and 
to soften the skin ; or, if the eruption be confined to 
the extremities, local ablution may be sufficient. These 
cases are benefited by the use of the sulphur waters of 
Harrowgate, Leamington, Crofton, and other well 
known springs, both internally and externally, and by 
the warm sea-water bath. In fact, these gently stimu- 
lant ablutions are often sufficient, if persevered in dur- 
ing several weeks, to remove the modifications of Lepra 
of which I am now speaking. 

But if the scales adhere tenaciously, or are accumu- 
lated into thick crusts (see Def. 2.,) then some more 
active lotion must be conjoined with the warm ablution. 



LEPRA. 33 

or with the application of steam, in order to clear the 
surface. Lotions of diluted alcohol, of sulphurated 
potass, or the decoction of dulcamara, will aid the 
exfoliation; and the thick crusts may be softened and 
loosened by lotions containing a portion of the liquor 
potassse, or of the muriatic acid. When these are re- 
moved, the cuticle may be restored gradually to its 
healthy condition, by the unguentum picis, or the un- 
guentum hydrargyri nitratis diluted with saturnine ce- 
rate, or simple ointment; or lotions containing a small 
proportion of the oxymuriate of mercury may he sub- 
stituted. The ointments should be applied at night, 
and washed off in the morning with warm water, or 
a slight saponaceous lotion. In a few cases, the conti- 
nued application of the tar ointment has effectually 
cleared the skin of the patches, and restored its tex- 
ture, even when internal remedies had little influence; 
but this advantage has not always been permanent. 

The same inert cases will be accelerated in their 
progress towards a cure, by the use of those internal 
remedies which tend to support the strength and to 
stimulate the cutaneous vessels. For this purpose the 
arsenical solution,* recommended by Dr. Fowler, is 
often extremely beneficial, in doses of four or five 
drops, which may be slowly increased to eight, and 

* Preparations of this mineral have a direct tendency to stimu- 
late the cutaneous circulation, and to inflame the skin ; and are, 
therefore, altogether inadmissible in the irritative forms, of Lepra, 
E 



34 SQUAMLE: 

persevered in for a month or more* Pitch, admini- 
stered in the form of pills, is productive of a similar 
good effect, where the cutaneous circulation is very 
inert; but both these medicines are liable to aggravate 
the eruption, where it is connected with much irritabi- 
lity of the skin. The solution of oxymuriate of mer- 
cury has appeared to have some efficacy in these inert 
states; and by thin and delicate girls, of relaxed habit, 
affected with the Lepra alphoides, the vinum ferri, or 
the tartrite before mentioned, has been taken with much 
advantage.f 

One of the most effectual remedies for Lepra, however, 
under all its varieties, is the decoction of the leaves and 
twigs of the solanum dulcamara, which was introduced 
to the notice of British practitioners by Dr. Crichton.J 
This medicine is at first administered in doses of two or 
three ounces thrice every day, which are gradually aug- 

* This active medicine being now not only sanctioned by the 
profession in general, but by the Pharmacopoeia of the College, it 
will be enough to state, that, in these smaller doses, which expe- 
rience has proved to be sufficient, it may be taken without any in- 
convenience. Another preparation, introduced by the late Dr. De 
Valangin, is kept at Apothecaries' Hall, under the name of solutio 
solventis mineralis, and is equally efficacious. 

t If in any case the tinct. lyttae prove useful in Lepra, it would 
probably be in these more inert instances. But it is to be observed 
that Dr. Mead, who originally recommended this medicine, was 
probably speaking, not of the scaly lepra, but of the leuce, or of 
the elephantiasis. See his Medicina Sacra, cap. ii. 

\ See his communication to Dr. Willan. (Treatise on Cutan. 
Diseases, p. 145.) His formula has been adopted by the College 
in the late edition of the Pharmacopoeia. 



LEPRA. 



35 



niented, until a pint is at length consumed daily. When 
there is a degree of torpor in the superficial vessels, the 
same decoction, made with a larger proportion of the 
shrub, is advantageously employed as a lotion; but if 
there is any inflammatory disposition, this and every 
other external stimulus must be prohibited. 

Where an irritable state of the disease exists, indeed, 
(and it is the most frequent,) nothing more stimulating 
than tepid water or thin gruel can be used for the pur- 
poses of ablution; and the arseniates, pitch, &c. above 
mentioned, must be excluded. The disease, under this 
condition, will be certainly aggravated by sea-bathing, 
by friction, by the external use of the strong sul- 
phureous waters, or of any irritant, as I have frequently 
observed: but it will be alleviated by the internal em- 
ployment of sulphur, with soda or nitre, or the hydrarg. 
sulphuratus niger with an antimonial, especially when 
conjoined with the decoction of dulcamara. The caus- 
tic potass, or liquor potassas of the L. Pharmacopoeia, in 
the dose of twenty or thirty drops, alone, or in combina- 
tion with the precipitated sulphur, is likewise beneficial; 
and the tinctura veratri, given in such doses as not 
to disorder the bowels, has occasionally removed this 
state of the disease. 

When the skin is highly inflamed, thickened, and 
stiff, of a vivid red colour, intermixed with a yellow- 
ish hue, (where the cuticle is separating in large 
flakes,) the heat, pain, and itching, are often extremely 
troublesome, and the motion of the limbs is almost 



.jO SQJJAMJi: 

impracticable. The most effectual relief is obtained, 
in these cases, by gently besmearing the parts with 
cream, or a little fresh and well washed lard, or butter. 

3. Lepra nigricans (Plate VIII. Fig. 2.) is a more 
rare variety of the disease, differing externally from the 
L. vulgaris chiefly in the dark and livid hue of its 
patches, which is most obvious in the margin, but even 
appears through the thin scales in the area of each 
patch.* The scales are more easily detached in this form 
of Lepra, and the surface remains longer tender, and is 
often excoriated, discharging bloody serum, till a new 
incrustation is formed. 

This variety of Lepra occurs in persons whose occu- 
pations expose them to the vicissitudes of the weather, 
and to a precarious diet, with fatigue, and watching. 
It is cured by nutritive food, with moderate exercise, 
followed by the use of the bark, mineral acids, and 
sea-bathing. 



II. PSORIASIS. 
The Psoriasis, or scaly tetter,] occurs under a con- 
siderable variety of forms, exhibiting, in common with 

•The melas of the ancients was deemed a superficial affection, 
resembling the alphos, except in its colour. "M^s colore ab 
hoc differt, quia niger est, et umbrae similis: caetera eadem sunt." 
(Celsus, loc. cit.) Possibly it included the pityriasis versicolor. 
See below, genus Hi. of this order, spec. 3. 

t The scaly tetter was denominated fisora by the Greeks, or 
sometimes rough and leprous psora. (See Aedus, tetr. iv. 1. cap. 
ISO, Sec.) But.the same generic term, with the epithet ulcer- 



PSORIASIS. 37 

lepra, more or less roughness and scaliness of the 
cuticle, with a redness underneath. It differs, however, 
from lepra in several respects. Sometimes the erup- 
tion is diffuse and continuous, and sometimes in sepa- 
rate patches, of various sizes; but these are of an irre- 
gular figure,* without the elevated border, the inflamed 
margin, and the oval or circular outline of the leprous 
patches: the surface under the scales is likewise much 
more tender and irritable in general than in lepra; and 
the skin is often divided by rhagades or deep fissures. 
It is commonly accompanied by some constitutional dis- 
order, and is liable to cease and return at certain seasons.f 
The causes of Psoriasis are nearly as obscure as those 
of lepra. It is not contagious; with the exception 

ating, or pustular, irapx eAxw^jjsj was applied to the humid tetter, 
(impetigo,) and perhaps also to scabies. As the appellation psora 
has been appropriated to scabies by many of the modern writers, 
Dr. Willan adopted the term psoriasis (which was chiefly used to 
denote a scaly affection of the eyelids and of the scrotum by the 
ancients) for the name of the genus. 

* Paul of JEgina, who treats of lepra and psoriasis together, 
points out the irregular figure of the latter as a principal distinc- 
tion, that of the former being orbicular. " Aevfcc per profunditatem 
corporum cutem depascitur orbiculatiore modo, et squamas piscium 
squamis similes dimittit : irapct autem magis in superficie haeret, 
et varie Jigurata est, &c." lib. iv. cap. 2. « De Lepra et Psora." 

t Celsus seems to have had this tetter in view, when describing 
his second species of impetigo, and comparing it with lichen. 
» Alterum genus est pejus, et simile papulae fere, sed asperius ru- 
bicundiusque, figuras varias habens : squamulse ex cute decidunt ; 
rosio major est? celerius ac latius procedit, certioribusque, quam 
prior, temporibus, et fit, et desinit: Rubra cognominatur," (lib 
v. cap. 28.) 



38 SQJJAMLE: 

perhaps of the first species, which Dr. Willan had 
observed to occur among children in the same school 
or family, at the same time; a circumstance, however, 
which I never witnessed. An hereditary predisposition 
to it is manifest in some individuals. Dr. Falconer 
has frequently traced it to sudden chills, from drinking 
cold water after being violently heated by exercise, — 
a cause to which lepra and other eruptive diseases are 
occasionally to be imputed.* Women, and especially 
those of a sanguineo-melancholic temperament, with a 
dry skin and languid circulation, are most liable to it: it 
affects them more particularly after lying-in, or during a 
state of chlorosis. And in children, it is not unfrequently 
produced by the many sources of irritation to which 
they are exposed. It is also sometimes observed in both 
sexes, connected with arthritic complaints; and we have 
seen it occur under states of great mental anxiety, grief, 
or apprehension. In those who are predisposed to this 
eruption, slight occasional causes appear to excite it: 
such as being over-heated by exercise; the unseasonable 
employment of the cold bath; a copious use of acid 
fruits, vinegar, or crude vegetables; and some peculiar 
mixtures of food. The first two species of the eruption 
are sometimes the sequel of lichen. 

* See Memoirs of the Med. Society of London, vol. iii In fact, 

Dr. Falconer, and even the nosologists down to our own time, in- 
clude the lepra, scaly tetter, and pustular impetigo, in their de- 
scription of lepra. See Vogel, de cogn. et curand. Homin. Affect, 
class. viii.§ 699. — Sauvages, Nosol. Meth. class, x. ord. 5. — Linn. 
Gen. Morbor. class, x. ord. 4. Cullen, Nosol. class, iii. ord. 3. 
gen. 88. 



PSORIASIS. 39 

Dr. Willan has given names to eleven varieties of 
Psoriasis, several of which are local, and require but a 
brief notice. 

1. The Psoriasis guttata (Plate IX. Fig. 1.) is a sort 
of connecting link between this genus and lepra, the little 
patches being distinct, and small, (seldom exceeding two 
or three lines in diameter,) but with an irregular cir- 
cumference, and the other peculiar characters just de- 
scribed. They appear on almost every part of the body, 
and even on the face; but in the latter situation they ex- 
hibit only a redness and roughness, without scales. 
This eruption is most common in the spring, at which 
season it is liable to recur for several years. It is pre- 
ceded by general pains, and slight feverishness. In chil- 
dren it often spreads rapidly over the body in two or 
three days; but in adults its progress is gradual and slow. 

2. The Psoriasis diffusa* (Plate IX. Fig. 2. X,XIL 
Fig. 1.) presents a considerable variety of appearances. 
In most cases it consists, of large patches, which are 
irregularly circumscribed, and exhibit a rough, red, and 
chopped superficies, with very slight scaliness inter- 
spersed. This surface is exceedingly tender and irritable, 
and is affected with a sensation of burning and intense 
itching, both of which are much augmented on ap- 
proaching a fire, on becoming warm in bed, or even on 

* Good specimens of this affection are given in Alibert's 13th 
and 14th plates; the former exhibiting it on the neck and ear 
(" Dartre squammeuse humide,") — the latter in a patch on the 
cheek (" Dartre squammeuse orbiculaire.") Liv. iii. 



40 SQUAMiE: 

exposure to the direct rays of the sun; but they are re- 
lieved by the impression of cool air. Sometimes these 
extensive eruptions appear at once; but, in other in- 
stances, they are the result of numerous minute eleva- 
tions of the cuticle, upon which small distinct scales, 
adhering by a central point, are soon formed, and which 
become gradually united by the inflammation of the 
intervening cuticle. As the disorder proceeds, the red- 
ness increases, and the skin appears thickened and ele- 
vated, with deep intersecting lines or furrows, which 
contain a powdery substance, or very minute scurf. The 
heat and painful sensations are much aggravated by the 
least friction, which also produces excoriation, and mul- 
tiplies the sore and painful rhagades. — This form of the 
disease is most frequent about the face and ears, and the 
back of the hands; the fingers are sometimes nearly 
surrounded with a loose scaly incrustation, and the nails 
crack and exfoliate: but it occasionally occurs on other 
parts of the body, either at the same time, or in succes- 
sion. It commonly begins with some general indisposi- 
tion; and a degree of erethism, with occasional sharp 
pains in the stomach, is sometimes kept up, during seve- 
ral weeks, by the constant irritation which it excites. Its 
duration is from one to four months, and sometimes much 
longer; and it is liable to return, in successive years, in 
the spring or autumn, and sometimes in both seasons. 

In other cases, the P. diffusa commences in separate 
patches, of an uncertain size and form, which become 
confluent, until they nearly cover the whole limb. 
Local instances also occur from local irritation; as in 



PSORIASIS. il 

the bakers itch (Plate XL) when the back of the hand 
is gradually covered with the rough scaly patches, inter- 
spersed with rhagades, and somewhat tumified; — and in 
the hands and wrists of washerwomen, from the irrita- 
tion of soap. In the latter variety, (Plate X. Fig. 2.) a 
diffuse inflammation surrounds the hands, wrists, and 
fingers, and from the whole of the affected surface the 
brittle cuticle separates in large irregular flakes in rapid 
succession. In infants, from two months to two years 
of age, this Psoriasis occasionally occurs in a severe 
degree, insomuch that Dr. Willan constituted the P. in- 
fantilis a distinct species. 

3. In the Psoriasis gyrata (Plate XII.) the patches 
are in stripes of a tortuous or serpentine form, resem- 
bling worms or leeches, or sometimes bending into 
rings. It is apt to be confounded with the vesicular 
and pustular ring-worm (herpes and impetigo). 

4. The Psoriasis inveterata (Plate XIII. Fig. 2.) is 
the most severe modification of the complaint, beginning 
in separate irregular patches, which extend and become 
confluent, until at length they cover the whole surface 
of the body, except a part of the face, or sometimes the 
palms of the hands and soles of the feet, with an uni- 
versal scaliness, interspersed with deep furrows, and a 
harsh, stiff, and thickened state of the skin. The pro- 
duction of scales is so rapid, that large quantities are 
found every morning in the patient's bed. The nails 
become convex, thickened, and opake, and are fre- 
quently renewed ; and, at an advanced period, especially 



42 SQUAIVLE. 

in old people, extensive excoriations sometimes occin*, 
with a discharge of their lymph, followed by a hard, dry 
cuticle, which separates in large pieces. In this extreme 
degree, it approaches very closely to the inveterate de- 
gree of lepra vulgaris in all respects; the only difference 
being in the form of the patches before they coalesce. 
It is sometimes the ultimate state of the Psoriasis dif- 
fusa; and occasionally a sequel of the prurigo senilis. 

The more local varieties of Psoriasis are the P. labi- 
alis, affecting the proiabium, especially of the under lip, 
the tender cuticle of which is thickened, cracks, and 
exfoliates, sometimes for a long period of time; — the P. 
palmaria* (Plate XIV.) an obstinate tetter, confined to 
the palm of the hand and wrist, which are rough, hot, 
and itchy, of a dirty hue, and cleft by deep furrows, 
which bleed when the fingers are stretched; — P. oph- 
thalmica, when the scaliness occurs chiefly about the 
angles of the eyes, producing an itching, inflammation, 
and thickening of the eyelids, with a watery discharge;! — 
the P. prcejmtii, which often accompanies the P. palma- 
ria, is characterized by painful fissures and thickening 
of the part, and is usually attended with phymosis; — 
and the P. scrotalis, in which scaliness, heat, itching, 
and redness, are followed by a hard, brittle texture of 
the skin, and by painful chaps and excoriations. 

The same general plan of treatment is applicable to 

* Well represented in M. Aliberi's 15th plate, under the title 
of " Dartre squammeuse centrifuge." 

t Galen distinguished the Psoriasis from the psorophthalmia. 
"Psoriasis autern exterius est; psorophthalmia internam palpe- 
bram, superiorem praecipue afficit." Galen de Oculo, cap. 7. 



PSORIASIS. 43 

the different modifications of Psoriasis, the period of its 
duration, and the degree of irritability, being carefully 
attended to. The popular practice, which hinges upon 
the old humoral hypothesis, consists chiefly in attempts 
to expel imaginary humours by evacuations, or to*cor- 
rect them by what are called antiscorbutics. But bleed- 
ing and repeated purging are injurious; and the vege- 
table juices, which an absurd notion of the scorbutic 
nature of the Psoriasis suggested, appear to be totally 
inefficacious. A more recent empiricism, which resorts 
to mercury in all affections of a chronic nature and of 
some obscurity, is not more successful: in fact, all these 
varieties of scaly tetter are ultimately aggravated by per- 
severance in a course of mercurials. 

In the commencement of the eruption, when it ap- 
pears suddenly, and the constitution is obviously disor- 
dered, a moderate antiphlogistic treatment must be pur- 
sued. A gentle purgative should be administered, and 
the diet made light, by abstracting every thing stimulant. 
This regimen, indeed, is requisite throughout the course 
of the disease, which is immediately aggravated in sym- 
pathy with irritation of the stomach, whether by spices, 
fermented liquors, pickles, or vegetable acids; whence 
the disuse of these articles contributes materially to its 
cure. 

But if the constitutional disturbance has subsided, 
the use of the fixed alkali, combined with sulphur lo- 
tum, or with an infusion of cinchona, together with 
tepid washing with simple water, or milk and water, will 
gradually remove the complaint. If the scaly patches 



i i SQUAMA: 

have extended over a considerable part of the bod] 
have assumed a more inert and chronic character, it 
must be viewed in a similar light with the lepra, and 
the remedies recommended for the first and second spe- 
cies of that disease must be resorted to. 

The shooting and burning pain and itching, in the 
early and more inflammatory stages of Psoriasis, induce 
the patient to seek anxiously for relief from, local exter- 
nal applications; but he is mortified to find that even 
the mildest substances prove irritants, and aggravate his 
distress. A decoction of bran, a little cream, or oil of 
almonds, sometimes produce ease; but any admixture, 
even of the oxide of zinc, or preparations of lead, with 
these liniments] is commonly detrimental. 

But the more local, and less inflammatory eruptions 
of Psoriasis are considerably alleviated by local expedi- 
ents. The P. palmaria is deprived of its dryness and 
itching by exposure to the vapour of hot water, by the 
use of gloves made of oiled silk, and by the applica- 
tion of the unguentum hydrargyri nitratis, diluted with 
the ung. cetacei or cerse, according to the degree of 
irritation in the skin. Sea-bathing, continued for 
many weeks, has been found an effectual remedy. The 
P. scrotalis and P. ophthalmica are also relieved by 
the same application, or the ung. hydrargyri praecipitati 
albi: but great care is requisite in the former case, to 
keep the parts clean by frequent ablution, and to pre- 
vent attrition. In the P. of the lips, nothing acrid can be 
borne; and much of the cure depends upon securing the 
parts from irritation, even from heat and cold, by a con- 



PITYRIASIS. 45 

stant covering of some mild ointment or plaster. In all 
these cases, some of the internal remedies above men- 
tioned must be at the same time employed, according 
to the period and other circumstances of the disease. 

III. PITYRIASIS. 

The Pityriasis is a very superficial affection, charac- 
terized by irregular patches of thin scales, which repeat- 
edly exfoliate and recur, but which never form crusts, nor 
are accompanied with excoriations. It is not contagious .* 

It occurs under three or four varieties of form. 

1. The Pityriasis capitis (Plate XV. Fig. 1.) which 
in infants is called dandriff, appears in a slight whitish 
scurf along the top of the forehead and temples, but in 
larger, flat, separate semi-transparent scales on the oc- 
ciput. A similar affection occurs on the scalp of aged 
persons.f 

It is only necessary to enforce a regular ablution of 

* These negative characters distinguish this eruption, especially 
when it affects the scalp, from the furfuraceous porrigo; a distinc- 
tion which the last-mentioned circumstance rendered important 
and necessary. The ablest of the later Greek writers, Alexander 
and Paul, have described the disorder, as consisting of " slight scaly 
and branny exfoliations, without ulceration." (See Alex. Trail, 
lib. i. cap. 4. — Paul. iEgin. lib. iii. cap. 3.) Yet all the transla- 
tors have rendered UtTvptdFi^ by the word fiorrigo; which, accord- 
ing to Celsus, comprehended the ulcerating pustules, or achores, of 
the Greeks, (De Med. lib. vi. cap. 2.) The use of the term Pity- 
riasis, therefore, to designate a dry and furfuraceous eruption, as 
distinct from the ulcerating porrigo, is sanctioned by authority, as 
well as by etymology, and pathological observation. 

t A good representation of Pityriasis on the occiput of an adult is 
given by Alibert,pl. 1 1 , which he calls " Dartre furfuracee volante." 



■46 SQ,UAMLE: 

the scalp with soap and water, or with an alkaline ov 
weak spirituous lotion; for which purpose the hair 
must be removed, if it be not thin. If this be neglected, 
the affection may ultimately degenerate into porrigo. 

2. The Pityriasis rubra occurs most frequently in 
advanced life, and is the result of a slight inflamma- 
tion of the portions of the skin affected, somewhat re- 
sembling in this respect the psoriasis diffusa. The cuti- 
cle is at first only red and rough, but soon becomes 
mealy or scurfy, and exfoliates, leaving a similar red 
cuticle underneath, which undergoes the like process; 
the scaliness becoming greater, as the exfoliation is 
repeated. This complaint is attended with a dry and 
unperspiring surface, a troublesome itching, and a feel- 
ing of stiffness. There is also a general languor and 
restlessness. When the redness and scales disappear, 
the patches are left of a yellowish or sallow hue. But 
the whole process is liable to be repeated at short inter- 
vals, and the disease to be thus greatly prolonged. 

The P. mbra is removed by a combination of anti- 
monials with the decoction of woods, and the warm 
sea-water bath. I have also seen it materially relieved 
by small doses of the tinctura veratri. Where the 
irritability of the skin is not very great, a gently re- 
stringent lotion or ointment, containing a portion of 
borax or alum, and super-acetate of lead, may be ap- 
plied to the parts affected with advantage. 

3. The Pityriasis versicolor (Plate XV. Fig. 2.) is 
most remarkable for the chequered and variegated dis- 



PITYRIASIS. 47 

coloration of the cuticle which it exhibits. It appears 
mostly about the breast and epigastrium, and sometimes 
on the arms and shoulders, in brown patches of different 
shades, variously branching and coalescing, and inter- 
spersed with portions of the natural hue.* In a few in- 
stances, it has extended over the whole back and abdo- 
men, even to the thighs, and slightly affected the face. 
There is generally a slight scurfy roughness on the dis- 
coloured parts; but this is in some cases scarcely percep- 
tible, and there is no elevation or distinct border to the 
patches. Dr. Willan states, that the P. versicolor " is not 
merely a cuticular disease; for when the cuticle is abrad- 
ed from any of the patches, the sallow colour remains, as 
before, in the skin, orrete mucosum." This, however, is 
not universal; fori have seen several instances of the erup- 
tion, in which the discoloured cuticle peeled off at inter- 
vals, in a thickened state, and a new cuticle was found un- 
derneath, of a red hue, as is usual under large exfoliations. 
The P. versicolor is usually of little moment ; for it is 
rarely accompanied by internal disorder, or by any 
troublesome sensations, if we except a slight itching on 
growing warm in bed, after strong exercise, or drinking 
warm or strong liquors. In those instances, however, 
where the eruption is very extensive, the itching and irri- 
tation connected with it are sometimes extremely dis- 

* These patches scarcely ever appear, like ephelides and freckles, 
on the face and hands, but chiefly on covered parts, as is remarked 
by Sennertus, who has given an accurate description of this erup- 
tion, under the appellation of " Maculae hepaticse," latinizing the 
popular German term, Leberjlechte. He considers it as the Melas, 
or dark variety of Vitiligo. See his Pract. Med. lib. v. part. iii. § I. 
cap. 7. 



43 SQUAMA: 

tressing, depriving the patients of their natural rest. In 
these cases the digestive organs are also commonly dis- 
ordered. But even when the eruption is not troublesome, 
great uneasiness is often occasioned by its appearance; 
since its brown and almost coppery hue frequently sug- 
gests, even to medical practitioners, the idea of a syphi- 
litic symptom. But a little experience will soon enable 
the observer to recognise the eruption, independently 
of the total absence of any tendency to ulceration, how- 
ever long its duration may be, and of every other con- 
comitant symptom of syphilis. 

The causes of this Pityriasis are not well ascertained. 
It occurs most frequently in those who have resided in 
hot climates, especially in its troublesome form. In one 
young gentleman it began after a year's residence in the 
Greek islands : it is also not uncommon in military and 
sea-faring people. The most extensive eruption that I 
have seen occurred in a custom-house officer, after drink- 
ing spirits freely during a day of fasting in the boat on the 
Thames. Fruit, mushrooms, sudden alternations of heat 
and cold, violent exercise with flannel next to the skin, 
have been mentioned as probable causes of this eruption. 

Internal medicines have not appeared to have much 
influence on this eruption, as Dr. Willan has stated. 
The oxygenated muriatic acid, however, I think, is 
possessed of some efficacy; and if the affection were of 
sufficient importance to induce the patient to persevere 
in swallowing medicine, the pitch pills* would probably 
be serviceable. By active external stimulants the dis- 

* See below, page 53. 



PITYRIASIS. 49 

order is often removed; as by lotions of strong spirit, 
containing the muriatic acid, or the caustic potass; one 
drachm of the former, or two or three of the liquor 
potassae, may be added to half a pint of distilled water. 
Sea-bathing is likewise beneficial, both as a remedy, and 
as a preventive of its recurrence. The more extensive 
and irritable eruptions of Pityriasis approximate some- 
what in their character to the psoriasis, and are allevi- 
ated by the same treatment. 

4. Pityriasis nigra. Subsequent to the period of 
his publication, Dr. Willan had observed a variety of 
Pityriasis in children born in India, and brought to this 
country, which commenced in a partially papulated 
state of the skin, and terminated in a black discolora- 
tion, with slight furfuraceous exfoliations. It sometimes 
affected half a limb, as the arm or leg; sometimes the 
fingers and toes.* 

IV. ICHTHYOSIS. 

The Ichthyosis, ox fish-skin disease, is characterized 
by a thickened, hard, rough, and in some cases almost 
horny texture of the integuments of the body, with 
some tendency to scaliness, but without the deciduous 

* M f Alibert has figured an eruption on the hand, which seems 
referable to this species, and which he denominates a " scorbutic 
ephelis." (See his plate 27, bis.) It appears to be the result of 
a degree of misery and filth, as little known in this country as the 
disease. 



50 SQUAMjE: 

exfoliations, the distinct and partial patches, or the con- 
stitutional disorder, which belong to lepra and psoriasis. 
1. Ichthyosis simplex. (Plates XVI, XVII.) In its 
commencement this disease exhibits merely a thickened, 
harsh, and discoloured state of the cuticle, which ap- 
pears, at a little distance, as if it were soiled with mud. 
When further advanced, the thickness, hardness, and 
roughness become much greater, and of a warty cha- 
racter, and the colour is nearly black. The roughness, 
which is so great as to give a sensation to the finger 
passing over it, like the surface of a file, or the roughest 
shagreen, is occasioned by innumerable rugged lines and 
points, into which the surface is divided. These hard pro- 
minences, being apparently elevations of the common 
lozenges of the cuticle, necessarily differ in their form 
and arrangement in different parts of the body, according 
to the variations of the cuticular lines, as well as in dif- 
ferent stages and cases of the complaint. Some of them 
appear to be of uniform thickness from their roots up- 
wards; while others have a short narrow neck, and broad 
irregular tops. The former occur where the skin, when 
healthy, is soft and thin; the latter where it is coarser, 
as about the olecranon and patella, and thence along the 
outside of the arms and thighs. On some parts of the 
extremities, however, especially about the ankles, and 
sometimes on the trunk of the body, these excrescences 
arc scaly, flat, and large, and occasionally imbricated, 
like the scales of carp. In other cases, they have ap- 
peared separate, being intersected by whitish furrows. 



ICHTHYOSIS. 51 

This unsightly disease appears in large continuous 
patches, which sometimes cover the greater part of the 
body, except the flexures of the joints, the inner and 
upper part of the thighs, and the furrow along the spine. 
The face is seldom severely affected; but in one case, in 
a young lady, the face was the exclusive seat of the dis- 
order, a large patch covering each cheek, and commu- 
nicating across the nose. (Plate XVIII.) The mammas, 
in females, are sometimes encased in this rugged cuticle. 
The whole skin, indeed, is in an extremely dry and un- 
perspirable condition, and in the palms of the hands and 
soles of the feet it is much thickened, and brittle. The 
disease often commences in childhood, and even in early 
infancy. 

This affection has been found to be very little under 
the control of medicine:* stimulating ointments and 
plasters have been industriously applied, with no mate- 
rial effect; and the disorder has been known to continue 
for several years, with occasional variations. Dr. Willan 
trusted to the following palliation by external manage- 
ment: " When a portion of the hard scaly coating is 
removed," he says, " it is not soon produced again. The 

* For examples of Ichthyosis the reader may refer to Panarolus 
(Petecoste v. obs. 9.) ; Van der Wiel (obs. xxxv. cent. 2.) ; Mar- 
vel. Donatus (Mirabil. lib. i. 3. ; or Schenck, Obs. Medic. Rarior. 
p. 699, where the same case is related); and Philos. Transact, vol. 
xxv. no. 160 — and vol. xlix. for 1755. See also the 37th plate of 
Alibert, in which the I. simplex is well represented. His appella- 
tion is « Ichthyose nacree." 



52 SQUAMA: 

easiest mode of removing the scales is to pick them oft 
carefully with the nails from any part of the body, while 
it is immersed in hot water. The layer of cuticle, which 
remains after this operation, is harsh and dry; and the 
skin did not, in the cases I have noted, recover its usual 
texture and softness: but the formation of the scales 
was prevented by a frequent use of the warm bath, with 
moderate friction." 

I have known the skin cleared of this harsh eruption 
by bathing in the sulphureous waters, and rubbing it 
with a flannel or rough cloth, after it had been softened 
by the bath; but the cuticle underneath did not recover 
its usual condition; it remained bright and shining; and 
the eruption recurred. Internally the use of pitch has in 
some instances been beneficial, having occasioned the 
rough cuticle to crack and fall off" and leave a sound 
soft skin underneath. This medicine, made into pills 
with flour, or any farinaceous powder, may be taken to 
a great extent, not only without injury, but with advan- 
tage to the general health; and affords one of the most 
effectual means of controlling the languid circulation, 
and the inert and arid condition of the skin.* Upon 

* A lady took for a considerable time from three drachms to 
half an ounce of pitch daily, with the most salutary effect both on 
her skin and general health. She had commenced with four pills, 
of five grains each, three times a-day, and gradually augmented 
the dose. — It may be remarked, that the unpleasant pitchy flavour 
of the pills is materially diminished, if they are kept for some 
time after being made up. 



ICHTHYOSIS. 53 

the same principle, the arsenical solution has been em- 
ployed in ichthyosis: in one case, in a little girl affected 
with a moderate degree of the disease on the scalp, 
shoulders, and arms, this medicine produced a complete 
change of the condition of the cuticle, which acquired its 
natural texture; but in two others no benefit was derived 
from it. The decoction of the inner bark of the elm 
has been said to be a specific for ichthyosis, by Plenck; 
but this originated in a misconception as to the use of 
the term.* 

2. Ichthyosis cornea. Several cases of a rigid and 
horny state of the integuments, sometimes partial, but 
sometimes extending nearly over the whole body, have 
been recorded by authors;! and occasionally such a con- 
dition of the cuticle has been accompanied with the ac- 
tual production of excrescences of a horny texture. 
These, however, are rare occurrences. 

The ordinary formation of horny excrescences in the 
human body, of which many examples have been de- 
scribed from the time of the Arabians downwards, is 5 

* The definition of ichthyosis given by Plenck, as well as the de- 
scription of" lepra ichthyosis," by Dr. Lettsom, on whose authority 
Plenck has mentioned this remedy, o bviously refers to the lepra 
vulgaris. See Plenck, Doctrina de Morb. Cutan. p. 89. — Lett- 
som, Med. Memoirs of the Gen. Dispensary, sect. iii. p. 152. 

f See Philos. Trans, no. 176, no. 297, and vol. xlviii. p. ii. p. 580, 
—Also Zacut. Lusitan. Prax. Hist. obs. 188. — Ephem. Acad. Nat. 
Cur. dec. i. p. 89. — Alibert has figured a singular case of " Ichthy- 
ose cornee," (plate 38) which resembles the case of the " porcu- 
pine man," described by Mr. Baker, Philos, Trans, vol. xlix. p. 1. 



54 SQDAlU/E. 

however, unconnected with any general rigidity of the 
cuticle. These excrescences have been improperly call- 
ed horns; for they are purely of cuticular growth, hav- 
ing no connection with the bones or other parts beneath, 
and consisting of a laminated callous substance, contort- 
ed and irregular in form, and not unlike isinglass in ap- 
pearance and texture.* They originate from two or 
three different diseased conditions of the cuticle; as from 
warts, encysted tumours, steatomata, &c. Morgagni 
has mentioned the growth of a horn on the sinciput of 
an old man, the basis of which was a wart; and other 
authors have noticed the same fact.f In the most nu- 
merous instances, however, they have arisen from the 
cavity of encysted tumours, of very slow growth, which 
were lodged under the cuticle of the scalp, or over the 
spine, after the discharge of their contained fluid. J In 

* " Cornua certe, quae hoc mererentur nomen, nunquam vidi ; : 
says M. Lorry, " seel varias excrescentias in corpore ct cute hu- 
mana innascentes, et extra cutem forma singular! succrescentes, 
quis non vidit ?" De Morbis Cutan. p. 520. — Yet our credulouf 
countryman Turner, declines treating of horns, because, he af- 
firms, "they are generally much deeper rooted than in the skin- 
arising from the cartilages or ligaments, or the bones themselves " 
On Diseases of the Skin, p. i. chap. xii. at the end. 

t Morgagni de Sedib. et Caus. Morbor. epist. lxv. art. 2. — Avi- 
cenna, who noticed the growth of horns on the joints, considered 
them as verrucous. Canon iv. fen. 7. tract, iii. cap. 14. See also 
Lorry, p. 519. — Plenck dc Morb. Cut. p. 98. 

| See two cases of this sort described by Mr. (now Sir Everard) 
Home in the Philosophical Transactions, vol. lxxxi. p. 1 ; and re- 
ferences to nine other cases of similar origin, in which the horny 



ICHTHYOSIS. DO 

one case, a horn of this sort was the result of inflamma- 
tion and discharge from a small steatomatous tumour of 
many years continuance.* Nearly the whole of these 
examples have occurred in women of advanced age. 

If these excrescences are sawed or broken off, they 
invariably sprout again. Excision, with the complete 
destruction of the cyst, or morbid secreting surface, is 
the only effectual remedy, when they have appeared, and 
a preventive during the growth of the primary tumour. 

excrescences were from four or five to twelve inches long: one of 
them eleven inches in length, and two inches and a half in circum- 
ference, is preserved in the British Museum. See also Medical 
Facts and Observations, vol. iii. Eph. Acad. Nat. Curios, dec. i. 
an. i. obs. 30 ; and dec. iii. an. v. app. — Hist, de la Soc. Roy. de 
Med. de Paris, for 1676, p. 316. — Bartholin. Hist. Anat. Rar. cent, 
i. 78. 

* See Memoirs of the Medical Society of London, vol. iv. app. 
p. 391. The reader will find other examples of horny excrescences 
in the works of Ingrassias, de Tumor, praet. Naturam, torn. i. p. 
336; Fabric. Hildan. cent. ii. obs. 25, 26 ; and many more refer- 
red to by Haller, Elem. Physiol, torn. v. p. 30. note. Malpighi 
has figured similar excrescences, originating from a morbid growth 
of the nails. Opera Posthuma, p. 99. and tab. xix. fig. 3 — 6. 



56 

Order III 
EXANTHEMATA 

RASHES. 

The term Exanthema, efflorescence, appears to have 
been used by the Greek writers in a very general sense, 
equivalent to that of our word emption;* and it has 
been employed, in this acceptation, by many modern 
authors. The nosologists, however, have limited it to 
those eruptions which are accompanied with fever, and 
which have their regular periods of efflorescence and 
decline. In this arrangement, it is appropriated solely 
to those appearances which are usually called rashes; 
(see Def. 3.) namely, to patches of superficial redness 
of the skin, of various extent and intensity, occasioned 
by an unusual determination of blood into the cutaneous 
vessels, sometimes with partial extravasation. It has no 
reference, therefore, to the existence of fever or con- 

* Hippocrates applies the term to numerous eruptions, which 
he often classes together, as to lichen, lepra, leuce (Praedict. lib. 
ii. ad finem ;) to miliary vesicles, and wheals (Epid. i. in the case 
of Silenus, some of which were prominent, like vari;) and to erup- 
tions resembling burns, flea-bites, bug-bites, &c. (Coac. Praenot, 
441. 39. ed. Foes. — Epidem. lib. 7. p. 359. 28. &c.) He speaks 
also of t« u,fjLv-)cw^tct. t^ctviie-^etjx, or excoriations (Coac. Praenot. 
444 ;) and applies the verb even to ulcers ;— c%*v6eet eXkix e? tjjv 
xtQxXiiv (de Morbo Sacro, § iii. p. 88.) He has likewise e^xv6t)Ta^ 
i^Kuhes, (aph. 20. lib. iii.) 



EXANTHEMATA: 57 

tagion, or to the duration and progress of the complaint. 
The first two genera of this order are contagious; the 
others are not. 



I. RUBEOLA*. 

MEASLES. 

The rash, in the measles, appear usually. on the fourth, 
but sometimes on the third, fifth, or sixth day of a fe- 
brile disorder, and, after a continuance of four days, 
gradually declines with the fever. The disease com- 
mences from ten to fourteen days after the contagion 
has been received, and appears under three varieties of 
form. 

1. Rubeola vulgaris. (Plate XIX.) The precursory 
fever of the measles is accompanied, especially on the 
third and fourth days, with a tenderness and some in- 
flammation of the eyes, and a slight turgescence of the" 
eyelids, together with a serous discharge both from 
the eyes and nostrils, which excites sneezing. There 
is likewise a frequent dry cough, with some degree 

* The continental writers in general have designated this disease 
by the term morbilli, the minor plague ; an appellation borrow d 
from the Italians, among whom il morbo (the disease) signified the 
filague (see Sennert. Med. Pract. lib. iv. cap. 12.) The terms 
Rubeola, Rubeoli, Roseola, Rossalia, Rossania, Sec. had been ap- 
plied, with little discrimination, to Measles, scarlet fever, eczema, 
Stc. until Sauvages fixed the acceptation of the first of them. 
H 



58 EXANTHEMATA: 

of hoarseness and difficulty of breathing, and often 
with a roughness or slight soreness of the throat. These 
symptoms are generally more severe in children than 
in adults, and are sometimes accompanied with slight 
delirium in the night. 

The rash, on the fourth day, begins to appear about 
the forehead and chin, and then over the rest of the face ; 
and on the following morning it is visible on the neck 
and breast, spreading towards evening over the trunk of 
the body, and lastly over the extremities. During this 
day the efflorescence in the face is most vivid ; but on 
the following (the sixth) day it begins to fade and 
subside, while the patches on the body are highly red. 
But these in like manner, begin to fade on the seventh 
day; and the patches on the back of the hand, which 
usually appear last (sometimes on the sixth or even 
seventh day of the fever,) do not always decline till the 
eighth. On the ninth day, slight discolorations only 
remain, which vanish before the end of the tenth. 

It is important, with a view to diagnosis, to attend 
accurately to the form of the rash. It first shows itself 
in distinct, red, and nearly circular spots, somewhat less 
than the ordinary areolae of flea-bites.* As these in- 
crease in number, they coalesce, forming small patches, 
of an irregular figure, but approaching nearest to that 
of semicircles or crescents.f These patches are inter- 

* See the excellent history of measles detailed by Sydenham, 
Obs. Med. sect. iv. cap. 5. 

t This observation, which is peculiar to Dr. Willan, is impor 



RUBEOLA. 



59 



mixed with the single circular dots, and with interstices 
of the natural colour of the skin: on the face, they are 
slightly raised, so as to give the sensation of inequality 
of surface to the finger passed over the cuticle. The 
whole face, indeed, is often sensibly swelled, at the 
height of the eruption; and occasionally the tumefac- 
tion of the eyelids is so great, as to close the eyes for 
a day or two, as in the smallpox:* but on the other 
£arts of the body they are not sensibly elevated. In 
many persons, however, as Dr. Willan has remarked, 
miliary vesicles appear, during the height of the efflo- 
rescence, on the neck, breast, and arms; and papulae 
often occur on the wrists, hands, and fingers. 

The catarrhal symptoms, and even the fever, are 
somewhat augmented on the appearance of the erup- 
tion; but the latter usually ceases, when the eruption 
declines. At this period, a diarrhoea commonly super- 
venes, if it had not occurred earlier, and affords relief 
to the other symptoms. This, however, is the period 
when the danger, which is a consequence rather than a 
concomitant of measles, commences: for now the 
catarrh is occasionally aggravated to acute inflammation 
of the lungs, of more obstinacy than ordinary pneu- 

tant ; for, though entirely overlooked by ordinary observers, it is 
commonly very manifest, and therefore a valuable diagnostic 
guide. 

* See Macbride, Introd. to Med. part ii. chap. 14. — Heberden, 
Med. Trans, of the Coll. of Phys. vol. iii. art. xxvi. and Comment" 
De Morb. cap. 6 3, 



60 EXANTHEMATA: 

monia, on which hectic sometimes supervenes, and 
ultimately hydrothorax, spitting of blood, or confirm- 
ed consumption. 

Other inflammatory affections, indicative of a ca- 
chectic condition of the system, are liable to occur at the 
close of the disease, and prove tedious and troublesome. 
In some, severe attacks of ear-ache, with deafness; in 
others, inflammation of the eyes and eyelids, of a more 
unmanageable character than the common ophthalmia; 
and in others, swellings of the lymphatic glands, take 
place. Sometimes the mesenteric glands become dis- 
eased, and marasmus ensues: and sometimes chronic 
eruptions on the skin, especially ecthymata, rupia, 
herpes, and porriginous pustules, with tumid lip, dis- 
charges behind the ears, and tedious suppurations, are 
the sequelae of the disease. 

The eruptive stage of measles, being seldom attended 
with danger, requires little medicinal treatment. It is 
chiefly necessary to open the bowels, to confine the 
patient to a light vegetable diet, with cold, subacid 
aqueous drinks, and to maintain a cool regular tempera- 
ture of the room. The usual diaphoretics and emul- 
sions have little influence over the fever or catarrh ; 
and the inhalation of steam, or the use of the pedilu- 
vium, is not more efficient:* but a steady refrigerant 
regimen, while it is grateful to the feelings of the pa- 

* Dr. Macbride (loc. cit.) and Dr. Willan have recommended 
the two last as palliatives. 



RUBEOLA. 61 

tient, contributes to repress present fever, restlessness, 
and delirium, and to diminish the inflammatory ten- 
dency of the disease in the lungs, eyes, &,c. on the de- 
cline of the eruption.* 

Almost all practitioners have concurred in the re- 
commendation of bloodletting in measles; some em- 
ploying it at the height of the eruption, which they 
deem the most inflammatory period, and some at the 
close of it, when pneumonic inflammation more com- 
monly supervenes; while others consider it as safe and 
beneficial at any period in or after the disease, where 

* I am indebted to Mr. Magrath of Plymouth, through the me- 
dium of my friend Dr. Lockyer, of the same place, for some im- 
portant instruction, respecting the safety and efficacy of the cold 
affusion during the fever and eruption of measles. Mr. Magrath 
favoured me with a perusal of the official reports of the treatment 
of a great number of patients in the hospital of the Mill prison, in 
which tlie practice was highly successful. He affirms that he has 
never witnessed any of the untoward circumstances which are usu- 
ally apprehended from cold, such as the retrocession of the erup- 
tion, increase of the catarrhal symptoms, Sec; but, on the con- 
trary, he is persuaded that the inflammatory affections of the 
chest, which are apt to supervene, on the decline of the rash, are 
prevented by the suppression of the. early excitement, to the vio- 
lence of which they are chiefly to be attributed. This accords 
strictly with well-established experience of the operation of cold 
in scarlet fever and small-pox. See an interesting case in illus- 
tration of the safety and advantages of this practice in measles, 
communicated to me by Mr. Magrath, in the Edin, Med. and 
Surg. Journal, for April 1814, p, 258. 



62 EXANTHEMATA: 

the symptoms are very distressing.* Dr. Heberden, 
indeed, contends that " bleeding, together with such 
medicines as the occasional symptoms would require in 
any other fever, is the whole of the medical care re- 
quisite in the measles." But Dr. Willan has placed 
this matter in the most judicious view. The mere op- 
pression of the respiration, with a labouring pulse, on 
the first or second day of the eruption, is common to 
other eruptive fevers, and usually disappears in the 
course of twenty-four hours. When, therefore, it is 
not accompanied by a hard cough and pains in the chest, 
it may be safely left to the natural termination, even in 
adults. But, on the other hand, when the eruption has 
disappeared, and these symptoms, together with diffi- 
culty of breathing, become severe, bleeding and cup- 
ping may be repeatedly necessary, aided by blisters, and 
demulcents, with anodynes. 

A diarrhoea frequently occurs at the close of the 
measles, which appears to alleviate the pneumonic 
symptoms, and to prevent some of the troublesome 
sequela? of the disease before noticed. Hence this eva- 
cuation should not be interrupted, at least for a few 
days; and laxatives should be administered, where it 
does not take place, as the most advantageous mode of 
allaying and preventing inflammatory symptoms. If the 
usual diarrhoea should be protracted, however, the pa- 

* Sec Morton De Morbiliis. — Sydenham, loc. cit. — Heberden, 
roc. cit. 



RUBEOLA* 63 

tient will require the support of light but nutritious diet, 
and cordials. 

2. Rubeola sine catarrho. (Plate XX.) This is a 
peculiarity, observed by Dr. Willan, in a few rare in- 
stances, during an epidemic Rubeola, which is only im- 
portant, as it leaves the susceptibility of receiving the 
febrile measles after its occurrence. The course and 
appearance of the eruption are the same as in the ^l. 
vulgaris; but no catarrh, ophthalmia, or fever accompa- 
nies it. An interval of many months, even two years, 
has been observed between this variety, and the subse- 
quent febrile Rubeola: but the latter more frequently 
takes place about three or four days after the non-febrile 
eruption* 

* The correctness of all the statements of writers before the 
close of the last century, in regard to the recurrence of febrile 
measles, is very questionable ; since the eruption had been con- 
founded with that of scarlatina down to this period. — Tozzetti, a 
physician of Florence; — Schacht, (Inst. Med. § i. lib. i. cap. 12) ; 
— Meza, (Compend. Med. fascic. i. cap. 20);— and de Haen (de 
Divis. Febrium, cap. vi. § vi. p. 106.) affirm that they have seen 
the measles more than once in the same individual ; while Rosen- 
stein (on the Dis. of Children, chap, xiv.) affirms, that during 
forty years he had never seen such a recurrence; and Morton, that, 
in the same period of practice, he had witnessed it but once. But 
Morton himself deemed scarlatina and measles only varieties of 
the same disease ! (De Morbili ; s et Scarlatina, cap. 4.) 

It cannot now be doubted, however, that exceptions occasionally 
occur in respect to measles, as well as to smallpox, and other con- 
tagious diseases, which in general aft'em individuals but once dur- 
ing life. Since my first edition was printed, I have met with two 



64 EXANTHEMATA: 

3. Rubeola nigra. (Plate XXI.) Dr. Willan ap- 
plied this epithet to an unusual appearance of the mea- 
sles about the seventh or eighth day, when the rash 
becomes suddenly livid, with a mixture of yellow. It is 
devoid of inconvenience or danger, and is removed in 
a week or ten days by the mineral acids. 



The limits of this Synopsis will not allow me to enter 
fully into the interesting inquiry, respecting the exist- 
ence of the contagious eruptive fevers in the time of the 
Greek and Roman physicians. The general inference 
in favour of the negative has arisen from the defect of 
such unequivocal descriptions of these formidable ma- 
ladies, as might have been expected in the writings of 
those, who have accurately delineated many other dis- 
eases of less moment, with which we are now familiar. 
But it appears to me, on the one hand, that this defect 
is perfectly explicable upon the ground of their absolute 
devotion to the humoral pathology, and of their syste- 
matic adoption of the dogmata of their predecessors; 
and, on the other, that there is a sufficient, though scat- 
tered, evidence in their works, to sanction the opposite 

papers by Dr. Baillie, in the 3d vol. of the Trans, of a Society for 
the Improv. of Med. and Chir. Knowledge (p. 258), which prove 
decisively that measles may occur a second time in the same indi- 
vidual, accompanied by their peculiar febrile and catarrhal symp- 
toms. His authority will not be questioned. 



RUBEOLA. G5 

conclusion. I shall here therefore briefly state the rea- 
sons of my belief in the affirmative of this question. 

It is almost superfluous to remark, that, from Galen, 
who adopted and extended the doctrine of the four hu- 
mours mentioned by Hippocrates, through the whole 
series of Greek writers, down to Actuarius, the same 
opinions were received with the utmost servility. They 
supposed that they had reached the perfection of medi- 
cal observation, when they had named the hypothetical 
humours which were believed to be in fault. They con- 
tented themselves, therefore, with classing together all 
the eruptive fevers as pestilential, and with referring the 
various eruptions, that accompanied them, to different 
combinations of the humours. Such eruptions were fre- 
quently mentioned by Hippocrates and Galen, under the 
appellation of erysipelata, herpetes, phlyctasnas, phlyza- 
cia, ecthymata, erythemata, exanthemata, &c. as the 
concomitants of malignant and epidemic fevers. Hippo- 
crates has generalized some of these observations, and 
has deduced especially the following prognostic respect- 
ing the eruptions of inflamed pustules (phlyzacia,) which 
seems referable only to the smallpox. " Quibus per fehres 
continuas <pxv&*ta. toto corpore nascuntur, lethale est, 
nisi superveniat apostema, quod fiat prsecipue circa 
awes."* 

But omitting, for the sake of brevity^ the detached 
passages relating to this subject, it will be sufficient, I 

* See his Coac. Praenot. n. 114. ed. Foes. See also Epidem. 
lib. ili. 

I 



66 EXANTHEMATA: 

think, to refer to a remarkable chapter of Herodotus, 
u On the treatment of eruptions ( f |*v^^r«) occurring in 
fevers," which has been preserved by Ae'tius * This 
Herodotus was an eminent physician of the pneumatic 
sect at Rome, in the reign of Trajan, more than half a 
century before Galen settled in that city. He describes 
first the herpetic eruptions "which appear about the 
mouth at the crisis of simple fevers," and subsequently 
the wheals of the febrile urticaria, the miliary vesicles, 
and I conceive, with considerable precision, the rashes 
of measles and scarlatina, and the pustules of smallpox. 
After mentioning the labial herpes, which occurs at the 
termination of catarrhal and other slight fevers, he says, 
" But in the early stages of fevers, which are not simple, 
but the result of vicious humours, there arise over the 
ichole body patches like flea-bites; and in the malignant 
and pestilential fevers, these ulcerate, and some of them 
have an affinity with carbuncles: all these eruptions are 
signs of the redundancy of corrupt and corrosive hu- 
mours in the habit: but those ichich appear on the face 
are the most' malignant of all." He then proceeds to 
describe the prognostics to be derived from the different 
appearances of these eruptions, almost in the same terms 
which the Arabian writers on the smallpox and measles 
subsequently used; and he was obviously acquainted 
with the danger of the highly confluent, and red or livid 
forms of these eruptions. " They are worse if numerous, 

* See his Tetrabib. il. ■ scrni. i. cap. 129. 



RUBEOLA. 67 

than if few, &c." — "Moreover," he remarks, "those 
which are extremely red are of the worst kind; but 
those which are livid, black, and tumid, like flesh that 
has been stained, are still more fatal; and these are co- 
pious on the face and breast, abdomen, sides, and back." 
He considers these cases as so desperate, that he advises 
the practitioner not to hazard his reputation by any ac- 
tive interference, lest the blame of their fatality should 
be imputed to his attempts. " For those eruptions," he 
asks, " which arise from beneath, in a mortifying state 
of the surface, what can they denote but that the life is 
passing from within?" 

Now, it seems unquestionable, that these, and much 
more ample details, delivered in the language of expe- 
rience, are applicable exclusively to the contagious 
eruptive fevers; i. e. to smallpox, measles, and scar- 
latina. For we are not acquainted with any other 
continued fevers, that are malignant and pestilential, 
in the early stages of which emptions appear all over the 
body, beginning like flea-bites, and sometimes ulcerating, 
i. e. suppurating especially on the face, except the dis- 
eases just mentioned. 

But the difficulty and rarity of original observation, 
even under more favourable circumstances, will be suf- 
ficiently manifest, if we trace the history of medical 
opinions upon the subject of the same diseases in later 
times. 

It might be supposed that, after the existence of these 
eruptive fevers had been so clearly pointed out by the 



W EXANTHEMATA: 

Arabians, their distinctive characters would have bees 
speedily ascertained, even by ordinary observers. But 
the fact was directly the reverse. Almost a thousand 
years elapsed, during which the smallpox, measles, and 
scarlet fever, continued to commit their ravages, and 
physicians continued to record them; while the indi- 
viduals, who were spared by one of these maladies, were 
seen to suffer successively from attacks of the others: 
nevertheless, they were still viewed through the eyes of 
the Arabians, and were universally deemed varieties of 
one and the same disease, until near the beginning of 
the eighteenth century: and it was not till towards the 
close of that age of enlightened observation, that the 
distinct character and independent origin of these three 
contagious disorders were universally perceived and 
acknowledged. 

We not only find the able and learned Sennertus, in 
the middle of the seventeenth century, discussing the 
question, " Why the disease in some constitutions as- 
sumes the form of smallpox, and in others that of mea- 
sles?"* but in the posthumous work of Diemerbroeck, 
an intelligent Dutch professor, published in 1687, it is 
affirmed that smallpox and measles differ only in de- 
gree. " Differunt (scil. morbilli) a variolis accidentaliter., 
vel quoad magis et minus."f And still later, the same 
assertion was made by J. Christ. Lange, a learned pro- 
fessor at Leipsic. " Praeterea tarn morbilli quam variolas 

* Medicin. Pract. lib. iv. cap. 12. 

t Tractat. de Variolis et Morbillis, cap. 14. 



RUBEOLA. 69 

sunt eruptiones in eo duntaxat discrepantes, quod vel 
minus vel magis appareant, &c."* But we must de- 
scend still nearer our own times, before we discover the 
complete unravelling of the subject, in the separation 
of scarlatina and measles, as distinct genera; although, 
as varieties, they had been pointed out even by Haly 
Abbas.f Our countryman Morton maintained the 
identity of these two exanthemata, and considered their 
relative connexion the same as that of the distinct and 
confluent smallpox. J And so late as the year 1769, 
Sir William Watson did not distinguish the measles 
from the scarlet fever.§ The publication of Dr. 
Withering's Essay on Scarlet Fever, in 1778, or rather 
of the second edition of that work in 1793, may be 
considered perhaps as the date of the correct diagnosis 
of this disease. So difficult is the task of observation, — 
so tardy the development of truth. || 

Surely, then, the imperfection of the knowledge 
of the ancients, respecting the nature of these eruptive 

*Miscell. Med. Curios. §xxxiv. 
t Theorice, lib. viii. cap. 14. 
J De Morbillis et Scarlatina, exercit. iii. 
§See his paper in the Med. Obs. and Inquiries, vol. iv. p. 132. 
II It is not the least curious circumstance in the history of me- 
dical discoveries, that the vulgar have, in many instances, led the 
way ; and have actually given distinctive appellations to many 
varieties of disease, before medical philosophers had learned to 
distinguish them. This is strongly exemplified in the history of 
chicken-pox (see the 2d note on varicella below) ; and also in 
scabies, cow-pox, Sec. 



70 EXANTHEMATA: 

fevers, affords no just inference against their existence; 
while, on the contrary, the brief but repeated notices, 
which they have transmitted to us, of eruptions resem- 
bling nothing that we are now acquainted with, except 
the contagious maladies in question, lead to the fair 
and legitimate conclusion, that the diseases of man- 
kind, like their physical and moral constitution, have 
not undergone any great and unaccountable change; 
and that the eruptive fevers have prevailed from the 
earliest ages. 



II. SCARLATINA.* 

The scarlet fever is characterized by a close and dif- 
fuse efflorescence, of a high scarlet colour, which ap- 
pears on the surface of the body, or within the mouth 
and fauces, usually on the second day of fever, and 
terminates in about five days. 

It is propagated, like the smallpox, measles, and 
chicken-pox, by a specific contagion ; and, like them P 
it affects individuals but once during life.f But it 

* This barbarous term, which appears to have been of British 
origin, having found admission into all the systems of nosology. 
Dr. Willan did not deem it expedient to reject it. 

t This fact is now fully ascertained. Dr. Withering, when he 
published the first edition of his tract, was of opinion, that the 
ulcerated sore-throat might occur in those who had undergone the 
Scarlatina anginosa; but, in the subsequent edition, he expresses 



SCARLATINA. 7 1 

commences after a shorter interval from exposure to 
the contagion than the disorders just mentioned; name- 
ly, on the third, fourth, or fifth day.* Adults, how- 
ever, are not very susceptible of the contagion; and, in 
them, the disease does not always appear so soon. 
Many medical practitioners, who have attended great 
numbers of patients affected with it, have never expe- 
rienced any of its effects. 

The Scarlatina appears under four varieties, in three 
of which the efflorescence occurs on the skin; viz. 
the S. simplex, anginosa, and maligna; and in the 
fourth, only in the mouth and throat; to which, there- 
fore, the appellation of Scarlatina has never been ap- 
plied. 

his conviction that he was in error. Among two thousand cases, 
Dr. Willan never saw the recurrence of the disease, under any of 
its forms. (See also Rosenstein on the Dis. of Child, cap. xvi.) 
Dr. Binns, indeed, mentions two instances of such recurrence at 
distant periods : but, at all events, these can only be looked upon 
as exceptions to the general fact, such as occur both in smallpox 
and measles. 

A further analogy is also observable between these diseases and 
Scarlatina; viz. the poison may operate locally, and even excite 
some secondary constitutional indisposition, in persons who have 
previously gone through the fever. Thus such persons, if much 
exposed to the contagion of Scarlatina, are liable to severe affec- 
tions of the throat, unaccompanied by the rash on the skin. 

* See Withering on the Scarlet Fever and Sore-throat, p. 61. — 
Heberden, Comment, de Morb. cap. 7, De Angina et Febre ru- 
bra, p. 20. — Dr. Blackburne states the interval to be « from four 
to six days." (On Scarlet Fever, p. 34.) 



72 EXANTHEMATA 

1. The Scarlatina simplex (Plate XXII.) consists 
merely of the rash, with a moderate degree of fever. 
The day after the slight febrile symptoms have appeared, 
the efflorescence begins to show itself, about the neck 
and face, in innumerable red points, which, within the 
space of twenty-four hours, are seen over the whole 
surface of the body. These, as they multiply, coalesce 
into small patches, but on the following day (the third) 
form a diffuse and continuous efflorescence over the 
limbs, especially round the fingers. On the trunk, 
however, the rash is seldom universal, but is distributed 
in diffuse irregular patches, the scarlet hue being most 
vivid about the flexures of the joints and the loins. On 
the breast and extremities, in consequence of the great 
determination of blood to the miliary glands and pa- 
pilla? of the skin, the surface is somewhat rough, like 
the cutis anserina, and several papulae are scattered on 
these parts. On the following (the fourth) day the 
eruption remains at its acme ; and on the fifth it be- 
gins to decline, disappearing by interstices, and leaving 
the small patches as at first.- On the sixth day it is 

* At this period, and on the evening of the second day, some 
attention is requisite to distinguish the scarlet rash from rubeola ; 
the observation of the crescent-like form of the patches of the 
latter, and the more diffuse and irregular shape of the former, will 
be a material guide. Tnis re-appearance of the rash in patches 
is noticed by Sennertus. " In statu vero, universum corpus ru- 
brum et quabi ignitum apparet, ac si universali erysipelate labo- 
raret. In declinaiione, rubor ille imminuit, et maculae rubrse 



SCARLATINA, 73 

indistinct, and is wholly gone before the end of the 
seventh. On the eighth and ninth days a scurfy de- 
squamation of the cuticle takes place. 

The efflorescence spreads over the surface of the 
mouth and fauces, and even into the nostrils, and is 
occasionally visible over the tunica albuginea of the 
eye: the papillae of the tongue too, which are consi- 
derably elongated, extend their scarlet points through 
the white fur which covers it. The face is often con- 
siderably swelled. There is usually great restlessness, 
and sometimes slight delirium, which appear to be 
much connected with the great heat of the surface, and 
continue in various degrees of severity, together with 
the fever, from three to seven days. A few patients 
escape without any fever, almost without indispo- 
sition. 

It is scarcely necessary to speak of the treatment of 
a disease, which has been pronounced, by great medical 
authority, fatal only " through the officiousness of the 
doctor."* The principal business of the practitioner, 
therefore, is to prevent the useless and pernicious ex- 
pedients of nurses ; but above all, to insist upon the 
coolness of the patient's apartment, and the lightness 
of his bed-clothes ; and to restrict him to the use of 



latae, ut in firincifiio, apparent, &c„" (De Febribus, lib. iv. cap. 
xii.) See also Etmuller. Opera, torn. ii. p. 416, where this cir- 
cumstance is accurately stated. 

* " Nimia medici diligentia." Sydenham, § vi. cap. 2. 
K 



74 EXANTHEMATA: 

cool drinks, and of light diet, without animal food. 
Moderate laxatives are also to be recommended. 

2. Scarlatina anginosa. (Plate XXIII. Fig. 2.) 
In this variety of Scarlatina, the precursory febrile 
symptoms are more violent, and an inflammation of the 
fauces appears, together with the cutaneous efflores- 
cence, and goes through its progress of increase and de- 
cline with it. Occasionally, however, the affection of 
the throat commences with the fever, and sometimes 
not until the eruption is at its height. 

With the first febrile symptoms, a sensation of stiff- 
ness and a dull pain on moving are felt in the muscles of 
the neck; and on the second day, the throat is rough 
and straitened, the voice thick, and deglutition painful. 
On this and the two following days, the symptoms of 
fever are often severe; the breathing is oppressed; the 
heat of the skin is more intense than in any other fever 
of this climate, rising to 106°, 108°, or even 112© of 
Fahrenheit's thermometer;* there is sickness, with 
headache, great restlessness, and delirium; and the 
pulse is frequent, but feeble: there is also an extreme 
languor and faintness. The tongue, as well as the 
whole interior of the mouth and fauces, is of a high 
red colour, especially at the sides and extremity, and 
the papilla? protrude their elongated and inflamed points 
over its whole surface. (Plate XXIII. Fig. 1.) 

* See Dr. Currie's " Reports on the Effects of Water, &c.'' 
vol. ii. p. 428. Sennert observes, « Calor ferventissimus." Loc. cit- 



SCARLATINA. 75 

The rash does not always appear on the second day, 
as in Scarlatina simplex, but not unfrequently on the 
third; nor does it so constantly extend over the whole 
surface, but comes out in scattered patches, which 
seldom fail to appear about the elbows. Sometimes too 
it vanishes the day after its appearance, and re-appears 
partially at uncertain times, but without any corre- 
sponding changes in the general disorder: the whole 
duration of the complaint is thus lengthened, and 
the desquamation is less regular. When the rash is 
slight, indeed, or speedily disappears, no desquama- 
tion often ensues; while, in other instances, exfolia- 
tions continue to separate to the end of the third week, 
or even later, and large pieces of the entire cuticle fall 
off, especially from the hands and feet. 

The tumour and inflammation of the throat often 
disappear, with the declining efflorescence of the skin, 
on the fifth and sixth day of the fever, without having 
exhibited any tendency to ulceration. Slight super- 
ficial ulcerations, however, not unfrequently form on 
the tonsils, velum pendulum, or at the back of the 
pharynx, sometimes early and sometimes later. Little 
whitish sloughs are seen, intermixed with the mottled 
redness; and when they are numerous, the throat is 
much clogged up with a tough viscid phlegm, which 
is secreted among them. When these are removed, 
after the decline of the fever, some excoriations remain , 
which soon heal. 

The S. anginosa is not unfrequently followed by a 



n , EXANTHEMATA: 

state oi" great debility, under which children are affected 
with various troublesome disorders, similar to those 
which more commonly supervene after the cessation oi 
rubeola.* But there is one affection peculiar to the 
decline of Scarlatina, which occurs especially when the 
eruption has been extensive; namely, anasarca of the 
face and extremities. This dropsical effusion is com- 
monly confined to these parts, and therefore unattended 
with danger: it usually appears in the second week after 
the declension of the rash, and continues for a fortnight 
or longer. But in a small number of cases, when the 
anasarca had become pretty general, a sudden effusion 
has taken place into the cavity of the chest, or into the 
ventricles of the brain, and occasioned the death of the 
patient in a few hours, of which I have witnessed two 
instances.! 

The principles, by which the treatment of Scarlatina 
anginosa should be regulated, have been satisfactorily 
established within the last few years; especially since 

*See above, p. 59. — Also Herberden, Comment, cap. vii. p. 20. 

t There is some difference of opinion as to the dangerous ten- 
dency of the dropsical state, which succeeds the scarlet fever. 
Dr. Will an never saw any considerable effusion take place into the 
internal cavities ; and several other writers look upon this dropsy 
as altogether harmless. (See Cullen, First Lines, § 664.— Dr. Jas. 
Sims on Scarlatina ang. in Mem. of the Med. Soc. vol. 1.) Other 
practitioners, however, have mentioned the occurrence of these 
effusions as of dangerous tendency, and not unfrequently fatal 
(See Plenciz, Tract, de Scarlatina ; — Frank de curand. Horn. Mor- 
bis, p. iii. § 295 ; — Vogel, de cognosc, et curand. Aff. § 154.) 






SCARLATINA. 77 

the influence of diminished temperature, in febrile dis- 
eases, was demonstrated by the late Dr. Currie, of Liv- 
erpool, and the effects of purgative medicines have been 
better understood. For we have thus acquired two in- 
struments, which are singly of the utmost value in the 
management of fever, and when combined are greatly 
auxiliary to each other. 

As a general rule, the Scarlatina anginosa must be 
submitted, from its commencement, to a strict antiphlo- 
gistic treatment. The extraordinary heat, the great 
restlessness, anxiety, and distress, and the other symp- 
toms of high excitement, which accompany the efflo- 
rescence, do not, indeed, require blood-letting, as was 
formerly supposed; on the contrary, that evacuation 
would, in most cases, occasion a hurtful waste of strength. 
But in respect to the moderate but free evacuation of 
the bowels, the use of cold drinks, and of external cold, 
and the interdiction of all stimulant and cordial ingesta, 
under this state of excitement, experience has clearly 
decided. 

The best writers on this disease agree in recommend- 
ing the exhibition of an emetic in the beginning of the 
fever; which some have deemed it advisable to repeat 
at intervals of forty-eight, or twenty-four hours, or even 
at shorter periods, according to the urgency of the symp- 
toms* An emetic is, doubtless, a safe, and perhaps an 
useful medicine, at the very onset of the disease: but 

* See Dr. Withering's Treatise before quoted. 



78 EXANTHEMATA: 

this active employment of them seems to be supported 
neither by experience nor by principle.* Some practi- 
tioners, indeed, combined the emetic with calomel, and 
ascribed a considerable portion of the advantage to the 
laxative operation.! Dr. Hamilton more lately has af- 
firmed, that moderate purgatives of calomel, with rhu- 
barb or jalap, are not only extremely beneficial, in the 
early stages of Scarlatina; but that they may supersede 
the use of emetics. J My own observation accords with 
this view of the subject. I have never witnessed any inju- 
rious effect from trusting to moderate purging, and have 
frequently seen the disease proceed with uniform secu- 
rity, where the affection of the throat was very consider- 
able, under the use of laxatives alone, with the cool 
treatment to be mentioned immediately. 

The value of moderate purgation, indeed, has been 
admitted by several cautious physicians. Dr. Willam 
although stating that " purgatives have nearly the same 
debilitating effects as blood-letting," observes, neverthe- 
less, that "the occasional stimulus of a small dose, as two 
or three grains, of calomel, is very useful;" and in the be- 

* There appears to be a considerable inconsistency in Dr. With- 
ering's recommendation of "larger doses" and " powerful vo- 
mits," in order " to secure a certain violence of action upon the 
system," and in the apprehension of the danger of their acting as 
purgatives, which he at the same time expresses, and principally 
from hypothetical considerations. (Log. cit. p. 78—81.)' 

t Dr. Rush. 

| See his Treatise on Purgative Med. 



SCARLATINA. 79 

ginning of the disease, he combined with it an equal 
portion of antimonial powder. The same combination, 
he informs us, was freely administered by a physician at 
Ipswich, in 1772, in larger doses; and of three hundred 
patients, thus treated, none died. (p. 357, note.) Dr. 
Binns* candidly acknowledges his Obligations to a medi- 
cal acquaintance, " for his removal of a prejudice against 
laxatives in the early stage of the disease, imbibed from 
various authors, and confirmed by the dreadful conse- 
quences he had seen, when a diarrhoea came on in this 
fever." But so far from producing injury, he was af- 
terwards satisfied, that the laxatives actually tended to 
prevent the diarrhoea which he dreaded.f 

* See his able account of the management of Scarlatina, when 
it prevailed in the large school at Ackworth, in Dr. Willan's trea- 
tise, p. 357. 

t It can scarcely be matter of surprise, that purgatives should 
have been deemed highly injurious in fevers, by those practitioners 
who were unacquainted with the cool treatment. For the extreme 
degree of depression and exhaustion, which the hot regimen oc- 
casioned, was a sufficient cause for a just apprehension of the ill 
effects of purgation. Mr. White informs us, when speaking of 
the miliary fevers of pueperal women, (which occurred under the 
depressing influence of that regimen,) that " a few loose stools, in 
some cases spontaneous, in others produced by art, have sunk pa- 
tients beyond recovery." (Treatise on the Management of preg- 
nant and lying-in Women, chap. 8.) 

We may remark, on the other hand, that the same artificial ex- 
haustion created a necessity for the copious use of wine and other 
stimulants, in these fevers, to prevent the patients from sinking 
irrecoverably. And hence a great two-fold mistake, in the treat- 



SO EXANTHEMATA: 

Many practitioners recommend the use of antimoni- 
als, and of saline and camphorated diaphoretics, in order 
to excite perspiration, during the first days of this fever; 
and some have advised the exhibition of opium in small 
doses, to alleviate the great inquietude and wakefulness 
that accompany it. But a little observation will prove, 
that such medicines fail altogether to produce either dia- 
phoresis or rest, under the hot and scarlet condition of 
tlr skin; and that, on the contrary, they aggravate the 
heat and dryness of the surface, and increase the thirst, 
the restlessness, the quickness of pulse, and every other 
distressing symptom.* In truth, the temperature is con- 
siderably too high to admit of a diaphoresis; and the only 

meut of fevers, was propagated ; viz. the fear of purgatives, and 
the excessive administration of stimulants. See Miliaria, infra. 

*SeeHuxham on the malignant ulcerous sore-throat; Fother- 
gill ; Grant; Plenciz, Sec. — Dr. Huxham, however, acknowledges 
the great difficulty of producing sweating hy any means. Dr. Wi- 
thering writes" Sudorifics. Cordials. Mexijiharmics. The me- 
dicines generally signified by these denominations have but little 
to do in the cure of Scarlatina. The patients are not disposed to 
sweat, when the scarlet rash prevails upon the skin, nor do I know 
of any safe method by which we could attempt to excite a diapho- 
resis, even if we should expect it to be advantageous." p. 81. — 
Di. Willan (p. 359) and Dr. Blackburne (Facts and Obs. &c. on 
Scarlatina, p. 27) make the same observation in stronger terms. 

With respect to opium, Dr. Withering observes, " I never saw 
it effect the purpose for which it was given; on the contrary, it 
visibly increased the distress of the patient." p. 91. Dr. Cotton 
has a similar remark. (See his " Obs. on a particular Kind of 
Scarlet Fever, that prevailed at St. Albans," 1749, p. 16.) 



SCARLATINA. ' 81 

cc safe" or effectual " method" of producing it (which 
was a desideratum with Dr. Withering) consists in re* 
during the heat, by the application of external cold, upon 
the principles established by Dr. Currie. 

We are possessed of no physical agent, as far as my 
experience has taught me, (not excepting even the use 
of blood-letting in acute inflammation,) by which the 
functions of the animal economy are controlled with so 
much certainty, safety, and promptitude, as by the ap- 
plication of cold water to the skin, under the augmented 
heat of scarlatina, and of some other fevers. This ex- 
pedient combines in itself all the medicinal properties 
which are indicated in this state of disease, and which 
we should scarcely a priori expect it to possess: for it is 
not only the most effectual febrifuge, (the " febrifugum 
magnum," as a reverend author long ago called it;*) but 
it is, in fact, the only sudorific and anodyne, which will 
not disappoint the expectation of the practitioner under 
these circumstances. I have had the satisfaction in nu- 
merous instances, of witnessing the immediate improve- 
ment of the symptoms, and the rapid change in the coun- 
tenance of the patient, produced by washing the skin. 
Invariably in the course of a few minutes, the pulse has 
been diminished in frequency, the thirst has abated, the 

* Dr. Hancoke, rector of St. Margaret's, Lothbury, published 
a pamphlet in 1722, entitled " Febrifugum Magnum ; or, Common 
Water the best Cure for all Fevers, &c." which contains many- 
sound observations and valuable facts, detailed in the quaint lan- 
guage of the time, 

L 



82 EXANTHEMATA: 

tongue has become moist, a general free perspiration 
has broken forth, the skin has become soft and cool, and 
the eyes have brightened; and these indications of relief 
have been speedily followed by a calm and refreshing 
sleep. In all these respects, the condition of the patient 
presented a complete contrast to that which preceded the 
cold washing; and his languor was exchanged for a con- 
siderable share of vigour. The morbid heat, it is true, 
w r hen thus removed, is liable to return, and with it the 
distressing symptoms; but a repetition of the remedy is 
followed by the same beneficial effects as at first.* 

Partly from the difficulty of managing the cold affu- 
sion, and partly from its formidable character in the esti- 
mation of mothers and nurses, imbued with the old 

* After the extensive evidence, which a period of more than 
twenty years has furnished, in proof of the uniform efficacy and 
security of the external use of cold water, in Scarlatina, and in 
other febrile diseases connected with high morbid heat of the skin 
it is to be lamented that some practitioners still look upon the 
practice as an cx/ieriment., and repeat the remnants of exploded 
hypotheses, about repelling morbid matter, stopping pores, 8cc. as 
reasons for resisting the testimony of some of the greatest orna- 
ments of the medical profession. For my own part, I have been 
in the constant habit of resorting to the practice at every oppor- 
tunity, in Scarlatina, (and also in typhoid fevers, during my super- 
intendance of the fever institution for the last twelve years,) at- 
tending to the simple rules laid down by Dr. Currie, and I have 
never witnessed any inconvenience, much less any injury from it, 
but an uniformity in its beneficial operation, of which no other 
physical expedient, with which I am acquainted, affords an ex- 
ample, 



SCARLATINA. 83 

prejudices, I have generally contented myself with re- 
commending the washing of the skin with cold water., 
or water and vinegar, more or less frequently and exten- 
sively according to the urgency of the heat. In the be- 
ginning of the disease, the affusion of a vessel of cold 
water over the naked body is, doubtless, the most effi- 
cacious: but, by a little management, all the benefits of 
a reduction of the morbid temperature, that can be 
expected at a subsequent period, may be obtained by 
the simple washing. In less violent cases, washing the 
hands and arms, or the face and neck, is of material 
advantage.* 

It is, of course, necessary to enjoin the cool regimen, 
as directed for the Scarlatina simplex; to attend to the 
ventilation and moderate temperature of the apartment; 

* For the direction of those who may not be acquainted with the 
principles of this practice, if any such remain in the profession, it 
may be stated, in the words of Dr. Currie, that the cold washing 
is invariably safe and beneficial, " when the heat of the body is 
steadily above the natural temperature, — when there is no sense of 
chilliness present,— -and no general or profuse perspiration." But 
I have found the following direction to the nurses amply sufficient; 
viz. to apply it, ' whenever the skin is hot and dry.' Dr. Stanger, 
in treating Scarlatina among the children of the Foundling Hos- 
pital, found no other precaution necessary. " Its effects in cooling 
the skin, diminishing the frequency of the pulse, abating thirst, 
and disposing to sleep, were very remarkable. Finding this appli- 
cation so highly beneficial," he adds, " I employed it at every pe- 
riod of the fever, provided the skin were hot and dry." See a note 
in Dr. Willan's Treatise, p. 360. 



84 EXANTHEMATA 

and to administer the drink cold.* Acidulated drinks 
are grateful, and, by coagulating the mucus secreted in 
the fauces, are beneficial to those parts. Dr. Willan 
and Dr. Stanger have recommended the oxygenated 
muriatic acid, in doses of half a drachm for adults, and 
ten or twelve drops for children, diluted in water, as an 
agreeable refrigerant. 

When there is a considerable degree of inflammation 
and tumefaction of the tonsils, rendering the act of de- 
glutition difficult, the application of a blister to the ex- 
ternal fauces has proved extremely beneficial.f Acidulat- 
ed gargles likewise afford a material relief, and probably 
contribute to obviate the diarrhoea, by preventing the 
acrid mucus from being swallowed. 

Wine, cinchona, and other cordials and tonics, are not 
only useless, but injurious, until after the efflorescence 
has declined, together with the febrile symptoms. Dur- 
ing the hot feverish state, the cold washing is, in fact, 
the best cordial; for, by allaying the excessive febrile 
action, it removes the cause of the extreme languor and 
depression, and thus prevents the tendency to those 

* Cold drink is, like the washing, always^salutary in the same 
hot and dry state of the skin, and tends, like it, to promote perspi- 
ration. 

t Drs. Willan, Heberden, Rush, Clark, and Sims have concur- 
red in the same observation. But Dr. Withering was of opinion 
that blisters were injurious, when the brain was affected; and that 
they were less advantageous, when the inflammation was confined 
♦o the fauces, than in other quinsies. 



SCARLATINA. 85 

symptoms of malignancy and putrescency, to obviate 
which the bark and wine have been supposed to be 
particularly required. The convalescence, likewise, is 
more rapid, and the tendency to dropsical effusions is 
less, when the violence of the febrile symptoms has 
been restrained by this expedient. It is advisable, how- 
ever, with a view to accelerate the convalescence, and 
to prevent anasarca, to resort to the cinchona, with mi- 
neral acids, and a little wine, as soon as the fever and 
rash have entirely disappeared. The same medicines, 
combined with diuretics, and small purgative doses of 
calomel, are generally efficacious remedies for the drop- 
sy, when it supervenes. 

3. Scarlatina maligna. This form of Scarlatina, 
although it commences like the preceding, shows in a 
day or two symptoms of its peculiar severity. The ef- 
florescence is usually faint, excepting in a few irregular 
patches, and the whole of it soon assumes a dark or livid 
red colour. It appears late, and is very uncertain in its 
duration; in some instances, it suddenly disappears a 
few hours after it is seen, and comes out again, at the 
end of a week, continuing two or three days. The skin 
is of a less steady and intense heat: the pulse is small, 
feeble, and irregular: the functions of the sensorium are 
much disordered; sometimes there is early delirium, and 
sometimes coma, alternating with fretfulness and vio- 
lence. The eyes are dull and suffused with redness, the 
cheeks exhibit a dark-red flush, and the mouth is in- 



So* EXANTHEMATA: 

crusted with a black or brown fur. The ulcers in the 
throat are covered with dark sloughs, and surrounded 
by a livid base; and a large quantity of viscid phlegm 
clogs up the fauces, impeding the respiration, and occa- 
sioning a rattling noise, as well as increasing the difficulty 
and pain of deglutition. An acrid discharge also distils 
from the nostrils, producing soreness, chops, and even 
blisters. These symptoms are often accompanied by 
severe diarrhoea, and by petechias and vibices on the 
skin, with haemorrhagy from the mouth, throat, bowels, 
or other parts, which, of course, but too often lead to a 
fatal termination. This generally takes place in the 
second or third week; but, in a few instances, the pa- 
tients have suddenly sunk as early as the second, third, 
or fourth day, probably from the occurrence of gangrene 
in the fauces, oesophagus, or other portions of the ali- 
mentary canal:* and sometimes, at a later period of the 
disease, when the symptoms had been previously mode- 
rate, the malignant changes have suddenly commenced, 
and proved rapidly fatal. Even those who escape through 
these dangers, have often to struggle against many dis- 
tressing symptoms, for a considerable length of time; 
such as ulcerations spreading from the throat to the 
contiguous parts, suppuration of the glands, tedious 
cough and dyspnoea, excoriations about the nates, &c. 
with hectic fever. 

* " Haec gangraena cesophagum, asperamque arteriam, saepe 
ante occupat, qua.r iilam percipere, iilique mederi queamus." 
Navier, in Com. de Reb. p. i. vol. iv. 338. 



SCARLATINA. 87 

The treatment of Scarlatina maligna must necessarily 
be different from that prescribed for the preceding spe- 
cies, and is unfortunately much less efficient. The ac- 
tive remedies, which operate so favourably in the S. an- 
ginosa, especially the cold washing are altogether out of 
place here; even the effect of a cathartic is admitted by 
the unprejudiced to be often deleterious, by rapidly sink- 
ing the powers of the constitution; and blisters are not 
always applied with impunity. On the whole, the prac- 
tice of administering gentle emetics appears to be bene- 
ficial, especially at the very onset of the disease. It is 
of great importance to remove frequently but in a gentle 
way, the viscid offensive matter that encumbers the 
fauces, and which, if swallowed, produces considerable 
irritation in the stomach and bowels. For this purpose, 
warm restringent gargles are useful; such as the decoc- 
tion of contrayerva, with oxymel of squills, or muriatic 
acid; an infusion of capsicum, or an acidulated decoc- 
tion of cinchona. Tincture of myrrh, camphorated 
spirit, and other stimulant liquids, may be likewise em- 
ployed with advantage. Fumigations, by means of the 
vapour of myrrh and vinegar, but particularly by the 
nitrous acid gas, (separated from powdered nitre by the 
strong sulphuric acid.) contribute materially to cleanse 
the fauces. The latter vapour, Dr. Willan states, often 
supersedes the necessity of gargles. 

As the disease advances, and the symptoms of malig- 
nancy or extreme debility increase, it becomes neces- 
sary to support the patient by moderate cordials, wine, 



88 EXANTHEMATA: 

opium, and the mineral acids, with light nourishment 
In this, as in other violent fevers accompanied with much 
sinking of the vital powers, it was formerly the custom to 
prescribe the cinchona copiously. But while the tongue 
is loaded, the face flushed, and the skin parched, I be- 
lieve this drug to .be always prejudicial. Much of this 
malignancy, indeed, may be often counteracted by pro- 
per ventilation; and where the cutaneous heat is great, 
and the surface dry, gentle tepid washings, especially in 
the early stages of the disease, contribute much to pre- 
vent the future depression. Subsequently, where there 
is great languor of the circulation in the skin, warm 
bathing or fomenting, or even the application of warm 
vinegar and spirits, has been attended with benefit. 

4. Similar treatment, both local and general, will be 
required in that variety of the disease, in which the 
throat is ulcerated, without any efflorescence on the skin : 
according to the degree of its virulence. 

The Scarlatina rapidly infects children, whenever it is 
introduced among those who have not already under- 
gone its influence in some one of its forms; insomuch 
that the most rigid separation of the diseased from the 
healthy, in schools or large families, has not always pre- 
vented its propagation. It is not accurately ascertained, 
at what period a convalescent ceases to be capable of 
communicating the infection: in some cases, the infec- 
tious power certainly remained above a fortnight after 



URTICARJA. 



89 



the decline of the efflorescence; and there seems to be 
little doubt that, so long as the least desquamation of the 
cuticle continues, the contagion may be propagated. 



III. URTICARIA, or NETTLE-RASH. 

The nettle-rash is distinguished by those elevations of 
the cuticle^ which are usually denominated wheals, 
(Def. 9.) They have a white top, but are often sur- 
rounded by diffuse redness. Dr. Willan particularly 
noticed six varieties of the complaint. It is not conf 
tagious. 

1. Urticaria febrilis.* (Plate XXIV. Fig. 2.) The 
rash, in this variety of Urticaria, is preceded for two 
days or more by feverish symptoms, with headache, pain 
and sickness at the stomach, and considerable languor^ 
anxiety, and drowsiness, and sometimes even by syncope. 
The wheals appear in the midst of irregular patches of 

* This form of the disorder has been accurately described by 
Juncker and others under the name of" Purpura urticata. (See 
his Conspect. Med. Pract. tab. 64 ; also Lochner, Eph. Nat. Cur. 
cent. vi. obs. 96; and Schacht, Inst. Med. Pract. cap. xi. § vi.) 
Sydenham has likewise described it, under the title of " Febris 
erysipelatosa ; (Obs. Med. § v. cap. 6.) and Suavages, as a variety 
of scarlatina, spec. 2. S. urticata. But Vogel pointed out its 
distinction from Purpura, Erysipelas, and scarlatina, (De cogn. 
et curand. Morb. § 158 de " Febre urticata.") See also Bur- 
serins " de Exanthemate urticata," torn. ii. cap. 5 j and Frank- 
"de curand, Horn. Morb." lib. iii. § 306. 



90 EXANTHEMATA: 

a vivid red efflorescence, sometimes nearly of a crimson 
colour, and are accompanied by an entreme degree of 
itching and tingling, especially during the night, or on 
exposing the parts affected, by undressing.* 

The eruption appears and disappears irregularly on 
most parts of the body, and may be excited on any part 
of the skin by strong friction or scratching.! The sur- 
rounding efflorescence fades during the day, and the 
wheals subside; but both return in the evening, with 
slight fever. The patches are often elevated, with a 
hard border; so that, when they are numerous, the face, 
or the limb chiefly affected, appears tense and enlarged. 

The febrile nettle-rash continues about a week, J 
with considerable distress to the patient, in consequence 
of the heat, itching, and restlessness, with which it is ac- 
companied: the disorder of the stomach, however, is re- 
lieved by the appearance of the eruption; but it returns 
if the eruption disappears. A slight exfoliation of the 
cuticle generally succeeds. 

This eruption occurs chiefly in summer; is often 
connected with teething or disordered bowels in chil- 
dren; and among adults, affects persons of full habit, 
who indulge in the gratifications of the table. 

Modifications of the febrile nettle-rash, indeed, are 

* u Find cnim singulars habent, quod in frigido magisemei- 
gant. el in cr.lido evanescant." VogeJ. See also B^rserius, § 96 ; 
and Frank, § 309. 

t See Sydenham ; and Frank, § 307. 

.j: " Febris primo scptenario inter sndores dccedit." Vogel 






URTICARIA. 91 

produced by certain articles of food, which, in particu- 
lar constitutions, are offensive to the stomach; especial- 
ly by shell-fish, such as lobsters, crabs, and shrimps, but 
above all by muscles.* In a few individuals, in conse- 
quence of a peculiar idiosyncrasy, other substances, 
when eaten, are followed by the same immediate affec- 
tion of the skin; such as mushrooms, honey, oatmeal, 
almonds, and the kernels of stone-fruit, raspberries, 
strawberries, green cucumber with the skin upon it,f 
&c. In some persons, the internal use of valerian has 
produced the nettle-rash J. The operation of these sub- 
stances is sometimes almost instantaneous,§ and the 
symptoms are extremely violent for several hours; but 
they generally cease altogether in a day or two. The 
eruption, however, is not always accompanied with 

* On some parts of the coast of Yorkshire, where muscles are 
abundant, a belief is prevalent among the people, that they are poi- 
sonous, and they are consequently never eaten. This opinion is 
most probably the result of traditional observation, in regard to 
the frequent occurrence of Urticaria, after they were swallowed. 
A case indeed is mentioned by Ammans, and Valentinus, in which 
a man died so suddenly after eating muscles, that suspicion of hav- 
ing administered poison fell upon his wife. (See Behrens, " Diss, 
de Affectionibus a comestis Mytillis.") 

fDr. Winterbottom, who is subject to this affection after eat- 
ing sweet almonds, observes that he takes them with impunity, 
when they are blanched. See Med. Facts and Obs. vol. v. where 
the symptoms are minutely described. 

| Dr. Heberden, Med. Transact, vol. ii. p. 176. — Frank, § 310. 

§ See Moehring de Mytilorum Veneno. segrot. iii. in Haller's 
Disput. torn. iii. p. 191. 



%2 EXANTHEMATA: 

wheals, but sometimes is a mere efflorescence, not un- 
like that of scarlatina. It is generally attended by great 
disorder of the stomach, with violent pains in the epi- 
gastrium, and other parts of the body, sickness, languors, 
fainting, with great heat, itching, stiffness, and often 
much swelling of the skin. In a few instances it is said 
to have been fatal.* 

An emetic of ipecacuanha, followed by a gentle laxa- 
tive, with light and cooling diet, (with total abstinence 
from fermented liquors, and from sudorific medicines,) 
constitute the sole treatment, which appears to be requi- 
site for the safe conduct of these disorders to their pe- 
riod of decline; at which time the cinchona, with sulphu- 
ric acid, is beneficial. 

2. The Urticaria evcmida (Plate XXIV. Fig. 1.) is 
a chronic affection, in which the wheals are not station- 
ary, but appear and disappear frequently, according to 
the temperature of the air, or the exposure of the pa- 
tient, and vary with the exercise which he uses, &c. It 
is not accompanied by fever, and seldom by any other 
derangement of health. The wheals are sometimes 
round; and sometimes longitudinal, like those which are 

* " Licet etiam ea symptomata, quamcunque gravia, intra unum 
alterumquc diem, sine vitae periculo deflagrare, aut extingui bo- 
lear.t ; tamen non desunt excmpla rariora, nobis quidem non visa, 
ubi mortem arcessiverunt." Werlhoff, Pref. to the Diss, of Dr. 
Bebrens, subjoined to his treatise « De Various et Anthracibirs," 
Hanov. 1735 ; also Van Swieten, Comment, ad aph. 723. 






URTICARIA, 9,3 

produced by the stroke of a whip: they may be excited 
on any part of the body, in a few seconds, by friction or 
scratching; but these presently subside again * They 
are sometimes slightly red at the base; but never sur- 
rounded by an extensive blush. A violent itching, with 
a sensation of tingling or stinging, accompanies the 
eruption; which, as in the febrile species, is most trou- 
blesome on undressing, and getting into bed. 

The disorder is extremely various in its duration. 
The eruptions, as Dr. Heberden remarks, last only a 
few days in some persons; while in others they continue, 
with very short intervals, for many months, and even for 
several years. f Persons affected with it are liable to 
suffer headache, languor, flying pains, and disorders of 
the stomach. It attacks people of all ages, and both 
sexes; but more especially those of sanguine tempera- 
ment, and females more frequently than males. 

As it is often obviously connected with irritability or 
some peculiar idiosyncrasy, of the stomach; so when ft 
continues long, Dr. Willan justly suggests the probabili- 
ty, that it originates from some article of diet, which 

* I knew a young lady, enjoying good health, who could, at any 
time, instantaneously excite long white and elevated wheals on 
her skin, by drawing the nails along it with some degree of pres- 
sure : but they soon subsided, and she was not subject to them 
from any other cause. The same cutaneous irritability coexists 
occasionally with impetigo, and other chronic affections of the 
skin, which have no relation to Urticaria. 

t Med. Trans, p. 175. See also his Commentar. cap. 36. De 
Essera. 



H EXANTHEMATA: 

disturbs digestion. Hence, he says, "I have desired 
several persons affected with chronic Urticaria, to omit 
first one, and then another article of food or drink, and 
have thus been frequently able to trace the cause of the 
symptoms. This appeared to be different in different 
persons. In some it was malt liquor; in others, spirit, 
or spirit and water; in some, white wine; in others, vine- 
gar; in some fruit; in others, sugar; in some, fish; in 
others, unprepared vegetables." He acknowledges, 
however, that in some cases, a total alteration of diet 
did not produce the least alleviation of the complaint. 
In such cases, occasional laxatives, and the mineral acids, 
have been found the most advantageous remedies. 
Sometimes, where the indigestion was considerable, I 
have found the soda or the caustic potass, combined 
with aromatic bitters, such as cascarilla, afford relief. 

The complaint is generally too extensive to be com- 
pletely alleviated by lotions of spirit, vinegar, or lemon 
juice, &c. which afford local relief. But the warm 
bath is beneficial; and a persevering course of sea- 
bathing, for a considerable time, has generally been 
found an effectual remedy. 

3. Urticaria perskms differs from the preceding- 
variety, principally in the stationary condition of the 
wheals, which remain after the redness, at first sur- 
rounding them, has disappeared. They continue hard 
and elevated, with occasional itching, when the patient 
is heated, for two or three weeks, and gradually sub- 



URTICARIA. 95 

side, leaving a reddish spot for some days. The 
treatment, directed for the foregoing species, is bene- 
ficial, 

4. In the Urticaria conferta, the wheals are more 
numerous, and in many places coalesce, so as to ap- 
pear of very irregular forms: they are also sometimes 
considerably inflamed at the base; and the itching is 
incessant. This variety of the complaint chiefly affects 
persons above forty years of age, who have a dry and 
swarthy skin; and seems to originate from violent exer- 
cise, or from indulgence in rich food and spirituous 
liquors. Hence the patients find little relief from medi- 
cine, unless they use at the same time a light cooling 
diet, and abstain from malt-liquor, white wines, and 
spirits. Alterative medicines, or tonics, are sometimes 
useful, if this plan of diet be conjoined with them; 
and warm bathing affords a temporary relief. The 
eruption often continues many weeks. 

5. The Urticaria subcutanea is a sort of lurking 
nettle-rash, that is marked by a violent and almost 
constant tingling in the skin, which from sudden 
changes of temperature, mental emotions, &c. is often 
increased to severe stinging pains, as if needles or 
sharp instruments were penetrating the surface. These 
sensations are at first limited to one spot on the leg or 
arm; but afterwards extend to other parts. It is only 
at distant intervals, that an actual eruption of wheals 



06 EXANTHEMATA: 

takes place, which continue two or three days, without 
producing any change in the other distressing symptoms. 
In persons so affected, the stomach is frequently at- 
tacked with pain, and the muscles of the legs are sub- 
ject to cramps. It is relieved by repeated warm-bathing 
in sea-water, and gentle friction. 

6. The Urticaria tuberosa (so called by Dr. Ft ) 
is marked by a rapid increase of some of the wheals 
to a large size,* forming hard tuberosities, which seem 
to extend deeply, and occasion inability of motion, and 
deep seated pain. They appear chiefly on the limbs 
and loins, and are very hot and painful for some hours: 
they usually occur at night, and wholly subside before 
morning,f leaving the patient weak, languid, and sore. 
as if he had been bruised, or much fatigued. It seems 
to be excited by excesses in diet, over-heating by exer- 
cise, and the too free use of spirits, and is often tedious 
and obstinate. A regular light diet and a course of 
warm-bathing are to be recommended, with occasional 



8 " Tumores vero, palmae latitudinem habentes, ct colore rubra 
sedobscuro instruct!, cum prurituad animi deliquium usque into- 
lerabili, universam corporis, sed femorum imprimis, superficiem 
occupare cernunlur.'' Frank, loc. cit. § 309. torn. iii. p. 108. 

t Some writers have hence considered this eruption as the Epi- 
nyctis of the ancients : but Senncrtus corrects this mistake. The 
epinyctides contained a bloody sanies, according to Galen, At-tius, 
and Paul : and Celsus says, " repcritur intus exulceratio mucosa.'* 






ROSEOLA. 97 

gentle laxatives, where the organs of digestion appear 
to be deranged.* 



IV. ROSEOLA. 

The efflorescence, to which Dr. Willan appropriated 
the title of Roseola, is of little importance in a practi- 
cal view;f for it is mostly symptomatic, occurring in 
connection with different febrile complaints, and re- 
quiring no deviation from the treatment respectively 
adapted to them. It is necessary, however, that prac- 
titioners should be acquainted with its appearances, in 
order to avoid the error of confounding it with the 
idiopathic exanthemata. It has been occasionally mis- 
taken both for measles and scarlet fever; and from this 
want of discrimination, probably, the supposition that 
scarlatina was not limited, like the other eruptive fevers, 
to one attack during life, has been maintained by many 
persons up to the present time. 

The Roseola is a rose-coloured efflorescence, va- 

* Frank, loc. cit. § 312. 

f Fuller (in his Exanthematologia, p. 128) speaks of this sort 
of rose-rash, as a flushing all over the body, like fine crimson, 
which is void of danger, and " rather a ludicrous spectacle, than 
an ill symptom." The appellation of Roseola is to be found in 
the works of some of the early modern writers ; but it was ap- 
plied somewhat indiscriminately to scarlet fever, measles, &c, 
fSee above, p. 56, note.) 



98 EXANTHEMATA 

riously figured, without wheals, or papula?, and not 
contagious. The principal varieties of it are comprised 
under the seven following heads. 

i. The Roseola wsliva (Plate XXV. Fig. 1.) is some- 
times preceded for a few days by slight febrile indispo- 
sition. It appears first on the face and neck, and, in the 
course of a day or two, is distributed over the rest of the 
body, producing a considerable degree of itching and 
tingling. The mode of distribution is into separate, small 
patches, of various figure, but larger and of more irre- 
gular forms than in the measles, with numerous inter- 
stices of the natural skin. It is at first red, but soon as- 
sumes the deep roseate hue peculiar to it. The fauces 
are tinged with the same colour, and a slight roughness 
of the tonsils is felt in swallowing. The rash continues 
vivid through the second day: after which it declines in 
brightness, slight specks only, of a dark red hue, re- 
maining on the fourth day, which, together with the 
constitutional affection, wholly disappear on the fifth. 

Not unfrequently, however, the efflorescence is par- 
tial, extending only over portions of the face, neck, and 
upper part of the breast and shoulders, in patches, very 
slightly elevated, and itching considerably. In this form 
the complaint continues a week or longer, the rash ap- 
pearing and disappearing several times; sometimes with- 
out any apparent cause, and sometimes from sudden 
mental emotions, or from taking wine, spices, or warm 
liquors. The retrocession is usually accompanied with 



ROSEOLA. 99 

disorder of the stomach, headache, and faintness; which 
are immediately relieved on its appearance. 

This variety of Roseola commonly occurs in summer, 
in females of irritable constitution; and is ascribed to 
sudden alternations of heat and cold, especially to drink- 
ing cold liquors after exercise. It is sometimes connect- 
ed with the bowel-complaints of the season. 

Light diet, and acidulated drinks, with occasional 
laxatives, alleviate the symptoms. The complaint is 
liable to retrocession, it is affirmed, from the influence 
of very chill air, or the application of cold water, which 
occasions considerable disorder of the head and ali- 
mentary canal; but I have not seen any instance of this 
kind. 

2. The Roseola autumnalis (Plate XXV. Fig. 2.) 
occurs in children, in the autumn, in distinct circular 
or oval patches, which gradually increase to about the 
size of a shilling, and are of a dark damask-rose hue. 
They appeal' chiefly on the arms, and continue about a 
week, sometimes terminating by desquamation. There 
is little itching, tingling, or constitutional affection, con- 
nected with this efflorescence; and its decline seems to 
be expedited by the use of sulphuric acid internally. 

3. The Roseola annulata (Plate XXVI. Fig. 1.) 
appears on almost every part of the body, in rose-co- 
loured rings, with central areas of the usual colour of 
the skin; sometimes accompanied with feverish symp- 



100 EXANTHEMATA 

toms, in which case its duration is short; at other times, 
without any constitutional disorder, when it continues 
for a considerable and uncertain period. The rings at 
first are from a line to two lines in diameter; but they 
gradually dilate, leaving a larger central space, some- 
times to the diameter of half an inch. The efflorescence 
is less vivid (and, in the chronic form, usually fades) in 
the morning, but increases in the evening or night, and 
produces a heat and itching, or prickling, in the skin. 
If it disappears or becomes very faint in colour for seve- 
ral days, the stomach is disordered, and languor, giddi- 
ness, and pains of the limbs ensue, — symptoms which 
are relieved by the warm bath. 

Sea-bathing and the mineral acids afford* much relief 
in the chronic form of this rash. 

4. The Roseola infantilis (Plate XXVI. Fig. 2.) is 
a closer rash, leaving smaller interstices than the R. 
cestiva above described, and occurring in infants during 
the irritation of dentition, of disordered bowels, and in 
fevers. It is very irregular in its appearances, some- 
times continuing only for a night; sometimes appearing 
and disappearing for several successive days, with violent 
disorder; and sometimes arising in single patches, in dif- 
ferent parts of the body successively. 

Where the rash is pretty generally diffused, it is often 
mistaken, as Dr. Underwood has remarked,* for mea- 

* On ihe Diseases of Children, vol. i. p. 87. 



ROSEOLA. 101 

sles and scarlatina. Whence it is necessary that prac- 
titioners should be acquainted with it; although it re- 
quires no specific treatment, but is alleviated by the 
remedies adapted to the bowel-complaints, painful den- 
tition, and other febrile affections, with which it is con- 
nected. 

5. Roseola variolosa. (Plate XXVII. Fig. 1, 2.) 
This rash occurs previous to the eruption both of the 
natural and inoculated smallpox, but not often before 
the former. It appears in about one case in fifteen, in 
the inoculated disease, on the second day of the erup- 
tive fever, which is generally the ninth or tenth after 
inoculation. It is first seen on the arms, breast, and 
face; and on the following day it extends over the trunk 
of the body and extremities. Its distribution is various: 
sometimes in oblong irregular patches, sometimes diffus- 
ed with numerous interstices; and, in a few cases, it 
forms an almost continuous redness over the body, be- 
ing in some parts slightly elevated. It continues about 
three days, on the second or last of which, the variolous 
pustules may be distinguished, in the general redness, 
by their rounded elevation, by their hardness, and by 
the whiteness of their tops. 

This rash is generally deemed, by inoculators, a cer- 
tain prognostic of a small and favourable eruption of the 
smallpox* It is not easily repelled by cold air or cold 

* Dr. R. Walker, indeed, speaking of the natural smallpox, says, 
" In every bad kind of smallpox, the eruption is ushered in by a 



102 EXANTHEMATA: 

drinks, against which the old inoculators enforced many 
prohibitions and cautions. 

These roseolous effloresences, antecedent to the erup- 
tion of smallpox, were observed by the first writers on 
the disease; and both by them and subsequent authors 
were deemed measles, which were said to be converted 
into smallpox. 

6. Roseola vaccini. (Plate XXVII. Fig. 3.) An 
efflorescence, which appears generally in a congeries of 
dots and small patches, but sometimes diffuse, like the 
variolous Roseola, takes place in some children on the 
ninth and tenth day of vaccination, at the place of inocu- 
lation, and at the same time with the areola that is form- 
ed round the vesicle; and from thence it spreads irregu- 
larly over the whole surface of the body. Rut this does 
not occur nearly so often as after variolous inoculation. 
It is usually attended with a very quick pulse, white 
tongue, and great restlessness. 

scarlet rash, which appears first upon the face, neck, and breast, 
and sometimes spreads over the whole body; it is observed some 
i>ait of the second day, and within twelve hours, sooner or later, 
the pimples emerge from these inflamed parts of the skin." See 
his " Inquiry into the Smallpox, Medical and Political,"' chap. viii. 
Edin. 1790. — But Dr. Willan remarks, that it is an universal efflo- 
rescence, of a dark red colour, with violent fever, that indicates a 
confluent eruption and a fatal disease. See Morton dc Variol. et 
Morb. p. 186. 



ROSEOLA. 103 

7. Roseola miliaris. This rash often accompanies 
an eruption of miliary vesicles, with fever. 

In simple continued fevers,* whether the bilious fever 
of summer, in this climate, or the typhus or contagious 
fever, an efflorescence resembling the Roseola (Estiva 
occasionally takes place, of a hue, however, more ap- 
proaching to that of measles. I have seen this efflores- 
cence in three cases of mild fever, in the House of Re- 
covery, at a late, period of its course; in two of which it 
was slight, and remained from two to three days. In 
the third case, it appeared on the ninth day of fever, in 
a young woman, after a sound sleep and a moderate per- 
spiration, in patches of a bright rose-pink colour, of an 
irregular oval form, somewhat elevated, and smooth on 
the surface, affecting the arms and breast, but most co- 
pious on the inside of the humeris. It was unaccom- 
panied by any itching or other uneasy sensation. All 
the febrile symptoms were alleviated on that day, and 
she did not keep her bed afterwards. On the following 
day the efflorescence had extended, the patches having 
become larger and confluent; but the colour, especially 
in the areas of the patches, had declined, and acquired 
a purplish hue in some parts, while the margins continu- 
ed red and slightly elevated. The whole colour on the 
third day had a livid tendency; and on the fourth, there 
were scarcely any perceptible remains of it, or of the fe- 
brile symptoms. 

* These roseolous spots are also sometimes connected with in- 
termittents. See Pechlin, Obs. Phvs. Med. lib. ii. 18. 



104 EXANTHEMATA: 

A roseolous efflorescence is sometimes connected 
with attacks of gout, and of the febrile rheumatism. I 
lately attended a gentleman of gouty habit, in whom a 
Roseola, accompanied with considerable fever, and with 
extreme languor and depression of spirits, total loss of 
appetite, and torpid bowels, subsisted a week upon the 
lower extremities, and also upon the forehead and ver- 
tex of the scalp. On the seventh day, the latter termi- 
nated by desquamation, and at midnight his knuckles 
and right foot were attacked with arthritic inflammation. 



V. PURPURA. 

This term is appropriated by Dr. Willan to " an efflo- 
rescence consisting of small, distinct purple specks and 
patches, attended with general debility, but not always 
with fever." The specks and patches, here mentioned, 
are petechice and ccchymomata, or vibices, occasioned, 
not, as in the preceding exanthemata, by an increased 
determination of blood into the cutaneous vessels, but 
by an extravasation, from the extremities of these ves- 
sels, under the cuticle. The Purpura,* in this arrange- 

* The term Purpura was applied to petechial spots only by Ri- 
verius, Diemerbroeck, Sauvages, Cusson, and some others. But 
it has been employed by different writers in so many other accep- 
tations, that some ambiguity would perhaps have been avoided by 
discarding it altogether: for some authors have used it as an ap- 
pellation for measles, others for scarlet fever, for miliaria, strophu- 
lus, lichen, nettle-rash, and the petechiae of malignant fevers. The 
title of h amorrhaa fietechialis, which was given to the chronic 



PURPURA. 105 

ment, is therefore intended to include every variety of 
petechial eruption, and of spontaneous ecchymosis; not 
only the chronic form of it, which is unaccompanied by 
fever, and which has received various denominations 
(such as haemorrhoea petechialis, petechiae sine febre,* 
land scurvy, &c. ;) but also that which accompanies ty- 
phoid and other malignant fevers. 

form of the eruption by Dr. Adair, in his inaugural thesis, in 1789, 
and which I adopted in my own dissertation upon the same sub- 
ject, in 1801, would perhaps have been more unexceptionable. 
But, in deference to Dr. Willan, I retain his term. 

* This appellation is generally ascribed to Dr. Graaf (see his 
Diss. Inaug. de Petech. sine Febre, Gott. 1775 ; but it was em- 
ployed half a century before his time by Rombergius (see Ephem. 
Nat. Cur. decad. iii. ann. 9 Sc 10, obs. 108 ; and Acta Phys. Med. 
Acad. Nat. Curios, vol. ix. obs. 21. p. 95.) The term was adopt- 
ed by many writers as expressive of the most remarkable feature 
of the disease; for petechiae had been generally deemed sympto- 
matic of fevers only. Whence also J. A- Raymann, whohas given a 
good history of the disease, called the spots " petechiae mendaces" 
in contradistinction from the febrile petechiae, which he denomi- 
nated " sincera." (See the Acta Phys. Med. for 1751, just quoted, 
p. 87.— See also Duncan's Med. Cases and Obs. p. 90 ; Med Com- 
ment, vol. xv. and xx. and Annals of Med. vol. ii. — Dr. Ferris 's 
ease, Med. Facts and Obs. vol. ii. 1791. — Dr.Zetterstrcem's Diss. 
Inaug. Upsal. 1797.) Amatus Lusitanus had also marked the 
absence of fever, about the year 1550, when he described the dis- 
ease under the similar title of " Morbus pulicaris sine febre ;" 
(Curat. Med. cent. iii. obs. 70) as had Cusson, who called it " Pur- 
pura afiyreta"— Pezoldus (obs. 6) and Zwingerus (Paedoiatreia 
Pract. p. 622) treated it under the appellation of "maculae nigrae 
fine febre " 



106 EXANTHEMATA: 

The chronic Purpura appears under three or four va- 
rieties of form: the first and second of which, however, 
seem to differ chiefly in the degree of severity of their 
symptoms. 

1. In the Purpura simplex (Plate XXVIII. Fig. 1.) 
there is an appearance of petechia?, without much dis- 
order of the constitution, except languor, and loss of the 
muscular strength, with a pale or sallow complexion, 
and often with pain in the limbs. The petechia? are most 
numerous on the breast, and on the inside of the arms 
and legs, and are of various sizes, from the most minute 
point to that of a flea-bite, and commonly circular. The) 
may be distinguished from recent flea-bites, partly by 
their more livid or purple colour, and partly because, in 
the latter, there is a distinct central puncture, the red- 
ness around which disappears on pressure. There i? 
no itching, or other sensation attending the petechia?. 

2. The Purpura hcemotrhagica* (Plate XXVIII. 
Fig. 2.) is considerably more severe; the petechias are 

* This term is not very correctly employed in this place ; since 
it implies that these more extensive eruptions, or rather extrava- 
sations, of Purpura are always accompanied by haemorrhages ; 
which is not the fact. 

By a sort of solecism, Sauvages has described this form of the 
disease under the title of stomacace universalis, class, ix. gen. 3. 
The Purpura simplex he terms phoenigmus petechials, class, x. 
gen. 32. 



PURPURA. 107 

often of a larger size, and are interspersed with vibices 
and ecchymoses, or livid stripes and patches, resembling 
the marks left by the strokes of a whip or by violent 
bruises. They commonly appear first on the legs, and 
at uncertain periods afterwards, on the thighs, arms, and 
trunk of the body; the hands being more rarely spotted 
with them, and the face generally free. They are usu- 
ally of a bright red colour when they first appear, but 
soon become purple or livid; and when about to disap- 
pear, they change to a brown or yellowish hue; so that, 
as new eruptions arise, and the absorption of the old 
ones slowly proceeds, this variety of colour is commonly 
seen in the different spots at the same time. The cu- 
ticle over them appears smooth and shining, but is not 
sensibly elevated: in a few cases, however, the cuticle 
has been seen raised into a sort of vesicles, containing 
black blood.* This more frequently happens in the 
spots which appear on the tongue, gums, palate, and 
inside of the cheeks and lips, where the cuticle is ex- 
tremely thin, and breaks from the slightest force, dis- 
charging the effused blood. The gentlest pressure on 
the skin, even such as is applied in feeling the pulse, 
will often produce a purple blotch, like that which is left 
after a severe bruise. 

* See Reil, Memorab. Clinic, vol. i. — Comment in Reb. Med. 
Sec. gestis, Leipsic. vol. vi.— Dr. Willan's Reports on the Dis. of 
London, p. 167. — Wolff, in Act. Nat. Cur. (before quoted) vol. yii. 
obs. 131. and Rogert, in Act. Reg, Soc. Med. Hauniensis, vol. 1 
p. 185. 



108 EXAINTHEMAtA: 

The same state of the habit which gives rise to these 
effusions under the cuticle, produces likewise copious 
discharges of blood, especially from the internal parts, 
which are defended by more delicate coverings. These 
haemorrhages are often very profuse, and not easily re- 
strained, and therefore sometimes prove suddenly fatal. 
But in other cases they are less copious; sometimes re- 
turning every day at stated periods, and sometimes less 
frequently and at irregular intervals; and sometimes 
there is a slow and almost incessant oozing of blood. 
The bleeding occurs from the gums, nostrils, throat, 
inside of the cheeks, tongue, and lips, and sometimes, 
from the lining membrane of the eyelids, the urethra, 
and the external ear; and also from the internal cavities 
of the lungs, stomach, bowels, uterus, kidneys, and blad- 
der. There is the utmost variety, however, in different 
instances, as to the period of the disease, in which the 
haemorrhages commence and cease, and as to the pro- 
portion which they bear to the cutaneous efflorescence. 

This singular disease is often preceded for some weeks 
by great lassitude, faintness, and pains in the limbs, 
which render the patients incapable of any exertion ; but, 
not unfrequently, it appears suddenly, in the midst of ap- 
parent good health.* It is always accompanied with ex- 

* See a case related by Dolsus, in the Ephemer. Nat. Cur. dec. 
ii. ann. iv. obs. 1 1 8, which occurred in a boy, " cujus omne corpus, 
absque dolore, febre, aut lassitudine praegressa, subito ur.a cum 
facie, labiis, et lingua, ubi mane adsurgeret, numerosissimis macu- 
11s lividis ct nigerrimis obsitum fuit, &c." — Similar cases are de- 



PURPURA. 109 

treme debility and depression of spirits: the pulse is 
commonly feeble, and sometimes quickened; and heat, 
flushing, perspiration, and other symptoms of slight fe- 
brile irritation, recurring like the paroxysms of hectic, 
occasionally attend. In some patients, deep-seated pains 
have been felt about the praecordia, and in the chest, 
loins, or abdomen; and in others, a considerable cough 
has accompanied the complaint, or a tumour and tension 
of the epigastrium and hypochondria, with tenderness 
on pressure, and a constipated or irregular state of bow- 
els. But in many cases, no febrile appearances have 
been noticed; and the functions of the intestines are often 
natural. In a few instances frequent syncope has oc- 
curred. When the disease has continued for some 
time, the patient becomes sallow, or of a dirty complex- 
ion, and much emaciated; and some degree of oedema 
appears in the lower extremities, which afterwards ex- 
tends to other parts. 

The disease is extremely uncertain in its duration: in 
some instances it has terminated in a few days; while in 
others it has continued not only for many months, but 
even for years. Dr. Duncan related a case to me, when I 
was preparing my thesis on this subject, which occurred 
in a boy, who was employed for several years by the 
players at golf to carry their sticks, and whose skin was 

scribed by Zvvingorus, in the Act. Nat. Cur. vol. ii. obs. 79. and 
by Werlhoff, in the Commerc. Liter. Norimberg. ann. 1735, hebd. 
7 Sc 2. In all these instances, the eruption was discovered on 
rising in the morning, having taken place during the night. 



110 EXANTHEMATA: 

constantly covered with petechiae, and exhibited vibices 
and purple blotches wherever he received the slightest 
blow. Yet he was, in other respects, in good health. 
At length a profuse haemorrhage took place from his 
lungs, which occasioned his death. When the disease 
terminates fatally, it is commonly from the copious dis- 
charge of blood, either suddenly effused from some im- 
portant organ, or more slowly from several parts at the 
same time. A young medical friend of mine was instan- 
taneously destroyed by pulmonary haemorrhage, while 
affected with Purpura, in his convalescence from a fever, 
after he had gone into Lincolnshire to expedite his re- 
covery:* and I have seen three instances of the latter 
mode of termination ; in all of which there was a con- 
stant oozing of blood from the mouth and nostrils, and at 
the same time considerable discharges of it from the 
bowels, and from the lungs by coughing; and in one, it 
was likewise ejected from the stomach by vomiting, for 
three or four days previous to death.f On the other 

* Several instances of sudden death, in this disease, from the 
occurrence of profuse haemorrhage, are mentioned by respec 'jle 
authors. See Lister, Exercit. dr Sec butb, p 96> &c. — Greg. 
Horst. lib. v. obs. 17. Two examples (one from pulmonary and 
the other from uterine haemorrhage) were communic. :d to me 
by my friend Mr, James Ramsey, of Ameisharr. one ' wrhi h oc- 
curred in his own familj-. 

■J- Two of those cases were described in my Report of tho 'dis- 
eases treated at the Dispensary, Carey-street, in the spring of 1810. 
See Edin. Med. and Surg. Journal, voi. vi. p. 574. 



PURPURA. Ill 

hand, I lately saw a case of Purpura simplex, in which 
the petechias were confined to the legs, in a feeble wo- 
man, about forty years of age, who was suddenly reliev- 
ed from the eruption and its attendant debility, after a 
severe catamenial flooding.* 

The causes of this disease are by no means clearly 
ascertained, nor its pathology well understood. It oc- 
curs at every period of life, and in both sexes ; but 
most frequently in women, and in boys before the age 
of puberty, particularly in those who are of a delicate 
habit, who live in close and crowded situations, and on 
poor diet, or are employed in sedentary occupations, 
and subject to grief and anxiety of mind, fatigue, and 
watching, f It has likewise attacked those who were 
left in a state of debility by previous acute or chronic 
diseases. In one of the fatal instances above mentioned, 
it came on during a severe salivation, which had been 
accidentally induced by a few grains of mercury, given, 
as I was informed, in combination with opium, for the 
cure of rheumatism. It has sometimes occurred as a 
sequela of smallpox, and of measles; and sometimes in 
the third or fourth week of puerperal confinement.! 
The disease, however, appears occasionally, and in its 
severest aud fatal form, where none of these circum- 

* See my Report for Jan. 1810, ibid. p. 124. — See also a case 
related by Wolff, in the Act. Acad. Natur. Curios, vol. iii. obs. 79. 

fSee Dp. Wilian's Reports on Dis. in London, p. 90. 

| See Joerdens, in Act. Acad. N. Cur. vol. vii. obs. 110 — This 
Is the Purpura symptomatica of Suavages, class, iii. gen. vi. spec. 3. 



1 12 EXANTHEMATA: 

stances existed: for instance, in young persons living in 
the country, and previously enjoying good health, with 
all the necessaries and comforts of life. 

This circumstance tends greatly to obscure the pa- 
thology of the disease. For it not only renders the 
operation of these alleged causes extremely question- 
able, but it seems to establish an essential difference in 
the origin and nature of the disorder, from that of 
scurvy,* to which the majority of writers have con- 
tented themselves with referring it. In scurvy, the 
tenderness of the superficial vessels appears to originate 
from deficiency of nutriment; and the disease is re- 
moved by resorting to wholesome and nutritious food^ 
especially to fresh vegetables and to acids: while in many 
cases of Purpura, the same diet and medicine have 
been taken abundantly, without the smallest alleviation 
of the complaint. In the instance of the boy men- 
tioned by Dr. Duncan, the remedies and regimen which 
would have infallibly cured the scorbutus, were liberally 
administered, without affording any relief; and in other 
cases, above alluded to, where a residence in the coun- 
try, and the circumstances of the patients, necessarily 

* I mean the true scurvy, formerly prevalent among seamen ir. 
long voyages, and among people in other situations, when living 
upon putrid, salted, dried, or otherwise indigestible food, yield- 
ing imperfect nutriment. See Lind, Trotter, Sec. on the Scurvy, 
and Vander Mye, de Morbis Bredanis. The symptoms are con- 
cisely detailed by Boerhaave in his 1 151st aphorism. 



PURPURA. 113 

placed them above all privation in these respects, the 
disease appeared in its severest degree. 

On the other hand, the rapidity of the attack, the 
acuteness of the pains in the internal cavities, the actual 
inflammatory symptoms that sometimes supervene, the 
occasional removal of the disease by spontaneous he- 
morrhage, the frequent relief derived from artificial 
discharges of blood,* and from purging, all tend to 
excite a suspicion that some local visceral congestion 
or obstruction is the cause of the symptoms in different 
instances. This point can only be ascertained by a 
careful examination of the viscera, after death, in per- 
sons who have died with these symptoms. The ancient 
physicians directly referred some of them, especially 
the haemorrhagies from the nose, gums, and other parts, 
to morbid enlargement of the spleen.f In one case, 
in which an opportunity of dissection was afforded at 
the Public Dispensary, and which occurred in a boy 
under the inspection of my friend and colleague Dr. 
Laird, the spleen, which had been distinctly felt during 

* See two cases of Purpura, related by an able and distinguished 
physician, Dr. Parry, of Bath, which were speedily cured by two 
bleedings from the arm. In both these cases, which occurred in 
a lady and an officer, the latter accustomed to free living, some de- 
gree of feverishness accompanied the symptoms of Purpura ; and 
the blood drawn exhibited a tenacious, contracted coagulum, co- 
vered with a thick coat of lymph. See Edin. Med. and Surg, 
Journal, vol. v. p. 7, for Jan. 1809. 

t See Celsus de Med. lib. ii. cap. 7. 
P 



Ill EXANTHEMATA: 

life protruding itself downwards and forwards to near 
the spine of the ilium, was found enormously enlarged. 
In another instance, which occurred under my own 
care, in a boy thirteen years old, the abdominal viscera 
were found to be sound; but a large morbid growth- 
consisting of a fleshy tumour, with a hard cartilaginous 
nucleus, weighing about half a pound, was found in the 
situation of the thymus gland, firmly attached to the 
sternum, clavicle, pericardium, and surrounding parts.* 
Cases not unfrequently occur, in which hepatic obstruc- 
tion is connected with Purpura. A man, habituated to 
spirit-drinking, died in about a fortnight from the com- 
mencement of an eruption of petechia?, which was soon 
followed by profuse and unceasing haemorrhage from 
the mouth and nostrils; but I had no opportunity of ex- 
amining the body. The jaundiced hue of the skin and 
eyes, however, with the pain in his side, dry cough, and 
quick wiry pulse, left no doubt of the existence of con- 
siderable hepatic congestion. And, lastly, I attended a 
young woman, about the same time, labouring under the 
third species of the disease (P. urticans), with a sallow 
complexion, a considerable pain in the abdomen, and 
constipation, without fever. While she was taking acids 
and purgatives, which had scarcely acted upon the bow- 
els, the pain on a sudden became extremely acute, the 

* This boy, though delicate, had enjoyed a moderate share of 
health, until ten or twelve days previous to his death, notwith- 
standing the diminution of the cavity of the thorax, occasioned 
by this tumour. Sec the Edin. Journal, vol. vi. just referred to. 



PURPURA. 115 

pulse frequent and hard, and the skin hot, with other 
symptoms denoting inflammation in the bowels, which 
were immediately relieved by a copious bleeding from 
the arm, followed by purgatives; after which the sallow- 
ness of the skin was gone, and the purple spots soon 
disappeared. 

These facts are not sufficient to afford any general 
inference, respecting the nature or requisite treatment 
of Purpura hemorrhagica; on the contrary, they tend 
to prove, that the general conclusions which are usually 
deduced, and the simple indications* which are com- 
monly laid down, have been too hastily adopted, and that 
no rule of practice can be universally applicable in all 
cases of the disease. 

In the slighter degrees of the Purpura, occurring in 
children who are ill fed and nursed, and who reside in 
close places, where they are little exercised; or in wo- 
men shut up in similar situations, and debilitated by want 
of proper food, and by fatigue, watching, and anxiety, 
the use of tonics, with the mineral acids and wine, will 

* I am sorry to be under the necessity of differing from my re- 
spected friend and preceptor, on this subject ; who would perhaps, 
subsequently, have deemed the following statement, respecting the 
method of cure in the hemorrhagic purpura, too general. " The 
mode of treatment for this disease is simple, and may be com- 
prised in a very few words. It is proper to recommend a generous 
diet, the use of wine, Peruvian bark, and acids, along with mode- 
rate exercise in the open air, and whatever may tend to produce 
cheerfulness and serenity of mind." See Reports on the Dis. of 
London, p. 93, for May 1797, 



116 EXANTHEMATA: 

doubtless be adequate to the cure of the disease, espe- 
cially where exercise in the open air can be employed at 
the same time.* But when it occurs in adults, espe- 
cially in those already enjoying the benefits of exercise 
in the air of the country, and who have suffered no pri- 
vation in respect to diet; or when it appears in persons 
previously stout or even plethoric; when it is accompa- 
nied with a white and loaded tongue, a quick and some- 
what sharp, though small, pulse, occasional chills and 
heats, and other symptoms of feverishness, however mo- 
derate; and if at the same time there are fixed internal 
pains, a dry cough, and an irregular state of the bowels ; 
— symptoms which may be presumed to indicate the ex- 
istence of some local congestion; — then the administra- 
tion of tonic medicines, particularly of wine, cinchona., 
and other warmer tonics, will be found inefficacious, if 
not decidedly injurious. In such cases, free and re- 
peated evacuations of the bowels, by medicines contain- 
ing some portion of the submuriate of mercury, will be 
found most beneficial. The continuance or repetition 
of these evacuants, must, of course, be regulated by their 
effects on the symptoms of the complaint, or on the ge- 
neral constitution, and by the appearance of the excre- 
tions from the intestines.f If the pains are severe and 

* In enumerating the remedies, mentioned in the preceding 
note, Dr. Willan lays the most particular stress upon this point, 
and adds, that u without air, exercise, and an easy state of mind, 
the etl'eci of medicines is very uncertain." On Cutan. Dis. p 461. 

t While these sheets were in the press, I received a valuable 
communication from my friend Dr. Harty, of Dublin, detailing the 



PURPURA. 



in 



fixed, and if the marks of febrile irritation are consider- 
able, and the spontaneous hemorrhage not profuse, local 
or general blood-letting may, doubtless, be employed 
with great benefit, especially in robust adults. 

When the urgency of the hemorrhagic tendency has 
been diminished by these means, the constitution rallies, 
though not rapidly, with the assistance of the mineral 
acids, and the decoction of cinchona, or cascarilla, or 
some preparation of iron, together with moderate exer- 
cise, and nutricious diet. 

3. The Purpura urticans (Plate XXIX.) is distin- 
guished by this peculiarity, that it commences in the 
form of rounded and reddish elevations of the cuticle, 
resembling wheals, but which are not accompanied, like 
the wheals of urticaria, by any sensation of tingling or 
itching. These little tumours gradually dilate; but, with- 
in 

result of his experience in this obscure disease; and it afforded 
me great satisfaction to learn, that, after having witnessed the death 
of a patient, who was treated in the ordinary way, with nutritive 
diet and tonic medicines, he has been uniformly successful in the 
management of upwards of a dozen cases, since he relied solely 
upon the liberal administration of purgatives. He prescribed ca- 
lomel with jalap, in active doses, daily, which appeared to be 
equally beneficial in the hemorrhagic, as in the simple purpura : 
the haemorrhages ceased, and the purple extravasations disappear- 
ed, after a few doses had been taken. 

This document being, in my estimation, too valuable to be lost, 
I transmitted it to Edinburgh, and it was published in the Medical 
and Surgical Journal, for April 1813. 



118 EXANTHEMATA: 

in one or two days, they subside to the level of the sur- 
rounding cuticle, and at the same time their hue be- 
comes darker, and at length livid. As these spots are 
not permanent, but appear in succession in different 
places, they are commonly seen of different, hues ; the 
fresh and elevated ones being of a brighter red, while 
the level spots exhibit different degrees of lividity, and 
become brown as they disappear. They are most com- 
mon on the legs, where they are frequently mixed with 
petechias; but they sometimes appear also on the arms 
thighs, breast, &c. 

The duration of the complaint is various, from three 
to five weeks. It usually occurs in summer and autumn, 
and attacks those who are liable to fatigue, and live on 
poor diet; or, on the contrary, delicate young women, 
who live luxuriously, and take little exercise. Some 
oedema of the extremities usually accompanies it, and it 
is occasionally preceded by a stiffness and weight of the 
limbs. 

The same rules of treatment apply to this, as to the 
preceding varieties of the disease. 

4 Purpura senilis. (Plate XXX.) I give this appel- 
lation to a variety of the complaint of which I have seen 
a few cases, occurring only in elderly women. It ap- 
pears principally along the outside of the fore-arm, in 
successive dark purple blotches, of an irregular form 
and various magnitude. Each of these continues from 
a week to ten or twelve days, when the extravasated 



ERYTHEMA. 119 

blood is absorbed. A constant series of these ecchy- 
moses had appeared in one case during ten years, and 
in others for a shorter period; but in all, the skin of 
the arms was left of a brown colour. The health did 
not appear to suffer; nor did purgatives, bloodletting, 
(which was tried in one case, in consequence of the ex- 
traordinary hardness of the pulse,) tonics, or any other 
expedient, appear to exert any influence ove,r the erup- 
tion. 

5. Purpura contagiosa* is introduced for the purpose 
of noticing the eruption of petechias, which occasionally 
accompanies typhoid fevers, where they occur in close 
situations: but as these are merely symptomatic, it would 
be superfluous to dilate upon the subject here. I may 
merely observe, in addition to the facts which I formerly 
communicated to Dr. Willan, respecting the occurrence 
of petechias in patients admitted into the Fever-House,f 
that such an efflorescence is very rarely seen in that 
establishment, 



VI. ERYTHEMA. 

The Erythema, like the roseola, is commonly symp- 
tomatic, and occurs with much variety in its form: yet 
sometimes, like the same efflorescence, it is the most 

* Purpura maligna of Suavages, spec. 3. 

tSee his Treatise on C atari. Dis. p. 468 and 469, note. 



12Q EXANTHEMATA: 

prominent symptom, and is, therefore, in like manner, 
liable to be mistaken for the idiopathic eruptive fevers 
This term is often erroneously applied to eruptions, 
which, together with redness, exhibit distinct papular 
and vesicular elevations;* as, for example, to the Ecze- 
ma produced by the irritation of mercury. 

In this arrangement, Erythema signifies "a nearly 
continuous redness of some portion of the skin, attended 
with disorder of the constitution, but not contagious.'* 
Dr. Willan has described six varieties, which will in- 
clude all the ordinary forms of the efflorescence. In 
some of them, as will appear from their titles, the sur- 
face is more or less elevated at some period of its course, 
approximating to the papular or tubercular tumours: but 
the&« are obscurely formed, and soon subside, leaving 
the redness undiminished. 

* The word £ pvBvpct , as used every where by Hippocrates, signi- 
fies sirnpl) redness ; and is therefore correctly appropriated 
affection, which diffeis from erysipelas, inasmuch as it is a mere 
rash or effibrescence (D--F 3.) and is not accompanied by any 
swelling, vesication, or regular fever. — Modern authors have not 
agreed in their distinctions between these two terms. Dr. Cuilen 
applies the word Erythema, to a slight affection of the skin, ap- 
pearing without fever, or attended by a secondary fever of irrita- 
tion ; and Erysi/iclas, to an affection of the skin, when it is the 
result, or symptomatic, of fever; making no distinction as to the 
termination in bullae, &c. See hisNnsol. Meth. gen. vii. spec. 2. ; 
and First Lines, § 274— Prof. Cailis; n deems Erythema only a 
lesser degree of erysipelas. See his Systema Chirurg. Hodiern. 
$ 483. 



ERYTHEMA. 121 

1. Erythema fugax consists of red patches, of an 
irregular form, and short duration, resembling the red- 
ness produced from pressure. These patches appear 
successively on the arms, neck, breast, and face, in va- 
rious febrile diseases, and in bilious diarrhoea, generally 
denoting, as Hippocrates and the ancients have observed, 
a tedious and dangerous disease. They sometimes oc- 
cur in chronic affections, especially those in which the 
primal vias are deranged; as in dyspepsia, hysteria, he- 
micrania, &c. 

2. The Erythema Iceve exhibits an uniformly smooth, 
shining surface, and chiefly appears on the lower ex- 
tremities, in confluent patches, and is generally accom- 
panied by anasarca. It affects young persons, who are 
sedentary, with slight fever, and terminates gradually, 
after an uncertain period, in extensive desquamation, as 
soon as the anasarca has disappeared. Exercise, with 
diuretics and corroborants contributes to shorten its du- 
ration in this class of patients. It occurs also in elderly 
persons, labouring under anasarca, (especially in those 
accustomed to excessive drinking,) and is liable to ter- 
minate in gangrenous ulcers. Indeed, under whatever 
circumstances anasarca occurs, so as to stretch the skin 
greatly, this Erythema is liable to be produced, and is 
often chequered with patches and streaks of a dark red 
or purple hue. Relief is afforded by the horizontal pos- 
ture of the limbs, by the internal use of diuretics and 



122 EXANTHEMATA: 

bark, and also by a weak spirituous lotion applied to the 
surface. 

It sometimes occurs, without oedema, when the bow- 
els have been much disordered, and occasionally, in 
women, at the menstrual periods. 

3. Erythema marginatum (Plate XXXII. Fig. 2.) 
occurs in patches, which are bounded on one side by a 
hard, elevated, tortuous, red border, in some places ob- 
scurely papulated: but the redness has no regular boun- 
dary on the open side. The patches appear on the ex- 
tremities and loins, in old people, and remain for an un- 
certain time, without producing any irritation in the 
skin. They are connected with some internal disorder, 
ana their occurrence is to be deemed unfavourable. 

4. The Erythema papulatam (Plate XXXI. Fig. 1.) 
occurs chiefly on the arms, neck, and breast, in exten- 
sive irregular patches, of a bright red hue, presenting 
not an inelegant painted appearance. For a day or two, 
before the colour becomes vivid, the surface is rough or 
imperfectly papulated. The redness afterwards con- 
tinues for about a fortnight; and as the eruption declines a 
it assumes a blueish hue, especially in the central parts 
of the patches. I have seen this eruption attended with 
great disorder of the constitution; especially with a fre- 
quent, small pulse, total anorexia, and extreme depres- 
sion of strength and spirits, and with acute pains and 
great tenderness of the limbs: but the general disorder 






ERYTHEMA. 123 

is often trifling.* Light diet, with diaphoretics, and the 
mineral acids, and an attention to the state of the bow- 
els, comprise all that is necessary in the treatment of 
this disorder. 

5. Erythema tuberculatum (Plate XXXI. Fig. 2.) 
resembles the last variety in the large irregular patches 
of red efflorescence, which it exhibits; but there are 
small slightly elevated tumours interspersed through 
the patches, which subside in about a week, leaving the 
Erythema, which becomes livid and disappears in about 
a week more. It commences with fever, and is accom- 
panied with great languor, irritability, and restlessness, 
and succeeded by hectic. In the only three cases of 
this Erythema, which had occurred to Dr. Willan, the 
medicines employed did not appear to alleviate the 
symptoms, or to prevent the subsequent hectic. I have 
not seen any instance of it. 

6. The Erythema nodosum, (Plate XXXII. Fig. 1.) 
which is a more common and milder complaint, seems 
to affect females only, and occurs on the fore part of the 
legs. It is preceded by slight febrile symptoms for a 
week or more, which generally abate when the Erythe- 
ma appears. It shows itself in large oval patches, the 
long diameter of which is parallel with the tibia, and 



* See Report of the Public Dispensary, Edin. Med, and Surg 
Journ. for Jan. 1812. 



124 EXANTHEMATA: 

which slowly rise into hard and painful protuberances, 
and as regularly soften and subside, in the course of 
nine or ten days; the red colour turning blueish on the 
eighth or ninth day, as if the leg had been bruised. It 
has always gone through its course mildly, under the use 
of laxatives, followed by the mineral acids, and other 
tonics. 

Under the head of Erythema Dr. Willan made men- 
tion of that form of intertrigo, which is produced in some 
persons, especially those of sanguine temperament and 
corpulent habit, by the attrition of contiguous surfaces* 
It most frequently occurs beneath the breasts, round the 
axilke, in the groin, and at the upper part of the thighs. 
Sometimes it is accompanied by a glairy fetid secretion; 
and sometimes the surface is dry, and the redness ter- 
minates in a scurfy or scaly exfoliation. An erythema- 
tous appearance, analogous to the intertrigo, is occasion- 
ed by acrimonious discharges, as by those of fluor albus, 
dysentery, gonorrhoea, &c. and by the irritation of the 
urine and alvine discharges, in infants, when a sufficient 
attention is not paid to the proper changes of their linen. 

The heat and uneasiness attendant on this complaint 
are allayed by frequent tepid ablution, which removes 

* Sauvages includes this variety of intertrigo, and the chafing 
and inflammation produced by riding on horseback, tight shoes, 
the use of tools, and even that of bedridden persons, under Ery- 
thema, denominating the former Erythema intertrigo (spec. 5.) 
and the latter E. fiaratrimma (spec. 6.) 






ERYTHEMA. 125 

the acrid secretion, where it occurs, and tends to pre- 
vent excoriation. If this takes place any simple oint- 
ment, or mild absorbent powder, will be applied with 
relief. 



126 

Order IV. 

BULLAE. 

In the the original sketch of his arrangement, Dr. 
Willan conjoined in one order, the three following gene- 
ra, Erysipelas, Pemphigus, and Pompholyx, and those 
which now constitute the order of Vesicles: but he was 
led to separate them in consequence of a just criticism 
of Prof. Tilesius, of Leipsic * The large and often ir 
regular vesications, which are termed Bullce (Def. 4.) 
discharge a watery fluid when they break; and the ex- 
coriated surface sometimes becomes covered with a flat 
yellowish or blackish scab, which remains till a new cu- 
ticle is formed underneath; and sometimes is converted 
into an ulcer, which does not readily heal. 

* This criticism was contained in a paper on herpetic eruptions, 
« Uber die fiechtenarii^en Aussc. a .," published in a Gei man 
periodical work, the Paradoxien of Dr. Martens, at Leipsic, 1802, 
ii band, i heft. Dr. Tilesius pointed out the improper application 
of Dr. Willan's definition of Bulla, " of a large size, and irregu- 
larly circumscribed." to the small, regular, and clustered vesicles 
of herpes; and he mentioned also the common inflamed base, upon 
which the herpetic clusters are sealed, the scabby crust which in- 
variably forms upon then., &c. as further grounds of separation. 
See p. 18 et seq. of the Paradoxien. — The substance of the de- 
scriptive part of this paper was inserted by myself in the M ciical 
and Physical Journal, for March 1804, vol. xi. p. 230, with an en- 
graving of the herpes zester. 



ERYSIPELAS 127 



I. ERYSIPELAS. 



The Erysipelas is a febrile disease, in which some 
part of the body is affected externally with heat, red- 
ness, swelling, and vesications. The tumour is soft, 
diffuse, and irregularly circumscribed, and not accom- 
panied by throbbing or acute pain. 

The last mentioned circumstances distinguish the 
tumour of Erysipelas from that of Phlegmon;* and 
the presence of tumour, together with vesication, dis- 
tinguishes the disease from Erythema. The disappear- 
ing of the redness on pressure, and its immediate re- 
turn when the pressure is removed, are commonly men- 
tioned among the characteristics of Erysipelas, by 
medical writers, from Galen downwards. This phas- 
nomenon, however, belongs to Erysipelas in common 
with several of the Exanthemata; as with the efflores- 
cence in scarlatina, in some varieties of roseola, and 
in erythema. 

The varieties of Erysipelas may be classed under 
four heads, namely, phlegmonous, oedematous, gan- 
grenous, and erratic.f 



* See Galen Meth. Med. cap. xiv. and Comment, in aph. 20 5 
Sib. vi. ; also Aetius, tetrab. iv„ serm. ii. cap. 59. 

f Galen speaks of Erysipelas fihlegfnonodes, and adematodes-, in 
which he has been followed by Forest, 0<>s. Chirurg. lib. ii. 1. 3 ? 
& 4; by Plater ? DeSuperfic. Corp. Dolore, cap. 17; and Frank, 



128 BULLAE: 

1. Erysipelas phlegmonodes. It is scarcely neces- 
sary to enter into a minute description of the well- 
known appearance of acute Erysipelas.* This form of 
it most frequently occurs in the face, affecting usually 
one side of it only; sometimes it seizes one of the ex- 
tremities; and in both cases it is ushered in by a smart 
feverish attack. The colour is higher than in the other 
species, and the burning heat and tingling in the part 
are exceedingly distressing. The swelling generally ap- 
pears on the second night, or third day of the fever; 
the vesications rise on the fourth and fifth, and break or 
subside on the fifth or sixth, when the redness changes 
to a yellowish hue, and the swelling and fever begin to 
diminish; — and on the eighth day both disappear; on 
the tenth, the new cuticle is commonly left exposed, 
the old one 1 having separated, and the brownish or dark 
scab, which had formed where the fluid of the vesica- 
tions had been discharged, having fallen off. — The pro- 
gress of the disease, however, is more rapid, and its 
duration shorter, in young and sanguine habits, than 
in those more advanced in life: in the former, the tume- 
faction is sometimes fully formed on the second day, and 
the whole terminates on the sixth or seventh; while in 
the latter, it may be protracted to the tenth or twelfth, 

De curand. Horn. Morbis, lib. iii. — Mr. Pearson divides Erysipelas 
into three species, adding the gangrenous to the two just men- 
tioned. See his principles of Surgery, chap. x. 

* Dr. Cullen has given an excellent history of the disease. First 
Lines. 1696. 



ERYSIPELAS. 129 

and the desquamation may not be completed before the 
fourteenth day. The vesications, in the latter instances, 
are often succeeded by a profuse discharge of acrimo- 
nious lymph, for several days, so that scabs do not 
form. Suppuration very rarely occurs in this species of 
Erysipelas, especially when it affects the face. 

2. The Erysipelas azdematodes is less severe in its 
attack: the tumour is more gradual in its rise and ex- 
tension, is of a paler red, or of a yellowish brown 
colour, and is accompanied by less heat and local dis- 
tress; its surface is smooth and shining; and if it' be 
strongly pressed with the finger, a slight pit remains 
for a short time.* Vesications, which are smaller, 
less elevated, and more numerous than in the former 
species, appear on the third or fourth day from the 
commencement of the swelling; and are succeeded, in 
two or three days, by thin dark-coloured scabs, giving 
an appearance not unlike the confluent smallpox, from 
the edges of which a clear lymph exudes. The whole 
face is much enlarged, so that the form of the features 
is scarcely recognised, and the appearance is not unapt- 

* Mr. Pearson observes, that " the part affected is almost wholly 
free from tension, and gives the sensation of an tsdematose or em- 
physematose state, except that there is no crepitation." He com- 
pares the sensation, on pressing a part in which a considerable for- 
mation of pus has taken place in Erysipelas, « to that which is 
excited by a quagmire or morass." loc. cit, 
R 



130 BULL.®: 

ly compared by Dr. Willan to that of a bladder distended 
with water. 

This species of Erysipelas is attended with consider- 
able danger when it affects the face, as above described : 
for the disorder of the functions increases with the 
advancement of the external disease. Vomiting, 
rigors, and delirium, followed by coma, takes place 
about the height of the disorder, and often terminate 
fatally on the seventh or eighth day; while in other 
cases, the symptoms continue undiminished, and death 
occurs at a later period; or a slow and tedious conva- 
lescence ensues. 

This form of Erysipelas most commonly affects per- 
sons of debilitated constitution, dropsical patients, and 
those who have long been subject to other chronic 
maladies, or live in habitual intemperance. It is not 
attended with danger, however, when it affects one of 
the extremities. In some unfavourable cases, matter 
is formed, which is apt to make its way through the 
cellular substance, producing irregular sinuses between 
the muscles, which it often materially injures, and pro- 
longing the sufferings of the patient for many weeks. 

3. The Erysipelas gangrenosum commences some- 
times like the one and sometimes like the other of the 
foregoing species, and most commonly occurs in the 
face, neck, or shoulders. It is accompanied with 
symptoms of low fever, and with delirium, which is 
soon followed by coma, which remains through the sub- 



ERYSIPELAS. 131 

sequent course of the disease. The colour of the 
affected part is a dark red; and scattered phlyctasnae, 
with a livid base, appear upon the surface, which fre- 
quently terminate in gangrenous ulcerations. Even 
when it terminates favourably, suppuration and gan- 
grene of the muscles, tendons, and cellular substance, 
often take place, producing little caverns and sinuses, 
which contain an ill-conditioned pus, together with 
sloughs of the mortified parts, which are ultimately 
evacuated from the ulcers. It is always a tedious and 
precarious disease, and irregular in the period of its 
termination. 

A peculiar variety of gangrenous Erysipelas occasion- 
ally occurs in infants, a few days after birth, especially 
in lying-in hospitals,* and is often fatal. Sometimes, 
indeed, infants have been born with livid patches, vesi- 
cations, and even gangrene already advanced-! It most 
frequently commences about the umbilicus or the geni- 
tals, and extends upwards, or downwards, affecting the 
parts which it reaches with moderate swelling, and slight 
hardness; the skin puts on a dark red colour, and vesi- 
cations with livid bases break out, terminating in spha- 
celus, which, if the child is not speedily cut off, nearly 
destroys some of the fingers, or toes, or even the geni- 
tals. In the milder cases, when the extremities alone 

* See Underwood on the Dis. of Children, vol. i. p. 31. (5th 
edit.) — and an ample account of it by Dr. Gartshore, in the Med. 
Communications, vol. ii. art. v. (1790)- — with some references. 

t See a case related by Dr. Bromfield, in the same vol. art. iv. 



132 BULL^: 

are affected, suppurations take place rapidly about the 
joints of the hands and feet. The complaint, however, 
often terminates favourably in ten or twelve days. 

4. In the Erysipelas erraticum the morbid patches 
appear, one after another, on different parts of the body; 
in some cases, those which appeared first remain till the 
whole eruption be completed ; in others the first patches 
decline, as fresh ones appear. Sometimes the disease 
thus travels progressively from the face downwards to 
the extremities.* It commonly terminates favourably, 
however, in a week or ten days. 

The exciting causes of Erysipelas are not always ob- 
vious: but it is commonly attributed to the action of 
cold air, after being heated; or to exposure to a strong 
heat, whether from the direct rays of the sun or from a 
fire; to intemperance; or to violent emotions of the mind, 
especially anger and grief. Erysipelas is likewise symp- 
tomatic of wounds and punctures, especially when the 
periosteum is injured, and of the local application of 
poisons, the stings of insects, &c.f 

* Mr. Pearson mentions this progression of the disease, as be- 
longing to the Erysipelas cedematodes; and adds, that each renew- 
ed accession of the complaint was less and less severe, as it reced- 
ed to a greater distance from the part first affected. § 308. See 
also Frank, lib. iii. § 281. 

| An erysipelatous affection, which has even proved fatal, has 
occasionally come on two or three days after inoculation, both va- 



ERYSIPELAS. 133 

It has been the subject of some discussion, whether 
Erysipelas is not sometimes propagated by contagion. 
The disease has been noticed, in several hospitals, to 
prevail in certain wards, among patients admitted with 
different complaints; but has seldom been known to 
spread in private houses. Dr. Wells, indeed, has col- 
lected several examples of the apparent communication 
of Erysipelas by contagion, which occurred in private 
families.* But such cases are, at all events, extremely 
rare, and perhaps never happened in well-ventilated and 
cleanly houses. From the Royal Infirmary, at Edin- 
burgh, this disease, like the puerperal fever, was ba- 
nished by ventilation, white-washing, and other means 
of purification; and it has not occurred in any hospital 
of late years, since a better system has been adopted in 
these respects. Other diseases, not infectious in them- 
selves, appear to become united with typhus, or conta- 
gious fever, under similar circumstances, and thus to be 
propagated in their double form; the dysentery,f for ex- 
ample, the peritonitis of women in child-bed, ulcerated 
sore-throat, &c. The simple phlegmonous Erysipelas, 
at all events, was never seen to spread like an infectious 
disease. 

The method of treatment must necessarily be widely 

riolous and vaccine, in children of irritable habits. See some cases 
in the Med. and Phys. Journal, for 1801. 

* See Transact, of a Soc. for the Improvement of Med. and 
Chirurg. Knowledge, vol. ii. art. xvii. (1800.) 

t See Dr. Harty's Observations on Dysentery, 



134 BULLiE: 

different in the phlegmonous, from that which the other 
forms of the disease require. In the ordinary cases of 
this species of Erysipelas, the principal plan of cure con- 
sists in the administration of moderate purgatives, with 
a light vegetable diet, and in enjoining repose of body 
and mind, and a cool apartment. Saline and other dia- 
phoretic medicines may be employed, as auxiliaries of 
secondary importance. Blood-letting, which has been 
much recommended as the principal remedy for the 
acute Erysipelas, is seldom requisite; and, unless there 
is considerable tendency to delirium or coma, cannot be 
repeated with advantage, at least in London, and other 
large towns.* Local bleeding and blistering may be 
substituted, in such cases, but not upon, or very near 
the diseased surface. The administration of cinchona 
and opium, in this form of the complaint, is certainly 
unnecessary, and appears to be of very equivocal safety, 
notwithstanding the authority upon which it has been 
recommended. 

In the Erysipelas cedematodes, and erraticum, the two 
last-mentioned remedies are highly useful, in accelerat- 
ing the decline of the disease, and relieving irritation, 
when the active symptoms of the first three or four days 
have been subdued b} purgatives and diaphoretics: or, 
if the functions of the sen onum were considerably dis- 
ordered, by a blister betw een the shoulders, or a topical 

* See Pearson's Principles of Suivery, §320. Bromfield's Chir. 
Obs. vol. i. p. 108;— also Prof. Callisen, Syst. Hodiern. § 491. 



ERYSIPELAS* 135 

bleeding in the same part. The strength should be sup- 
ported, during the decline of the complaint, by a more 
cordial regimen, with a view to obviate the tendency to 
gangrene. 

In the Erysipelas gangrenosum, even in infants,* the 
bark is necessary, in considerable doses, through the 
whole course of the disease: Opium also, camphor, the 
mineral acids, with wine, and the general regimen adapt- 
ed to gangrenous affections occurring under other cir- 
cumstances, must be freely employed. The formation 
of sinuses, the separation of sphacelated parts, &c. will 
require surgical attention for some time. 

With respect to external applications in the early 
stages of Erysipelas, experience seems to have decided 
that they are generally unnecessary, if not prejudicial.! 
The application of powdery substances has commonly, 
according to my own observation, augmented the heat 
and irritation in the commencement; and afterwards, 
when the fluid of the vesications oozes out, such sub- 
stances produce additional irritation, by forming with 
the concreting fluid, hard crusts upon the tender sur- 

* " In tenellis infantibus observatum fuit Erysipelas a ca^isa ab- 
scondita, saepissime lethali, nisi corticis usu occurratur malo.' 5 
Callisen, § 493. — See also Underwood, and Garthshore, before 
quoted. 

f " Externa reraedia vesolventia, emollientia, adstringentia, vel 
calida, vel frigida,— uti quoque pulveres varii, parum vel nihil 
in erysipelate prosunt ; nee omnis noxae suspicionem, experientia 
teste, efFugiunt.** Callisen. 



136 BXJLLM: 

face*. In order to allay the irritatiou, produced by the 
acrid discharge from the broken vesications, Dr. Willan 
recommends us to foment or wash the parts affected, 
from time to time, with milk, bran and water, thin gruel, ■ 
or a decoction of elder flowers and poppy heads. In the 
early state of the inflammation, when the local heat and 
redness are great, moderate tepid washing, or the appli- 
cation of a cool but slightly stimulant lotion, such as the 
diluted liquor ammonias acetatis, has appeared to me to 
afford considerable relief. 

The zona, zoster, or shingles, is considered as a va- 
riety of Erysipelas by the nosologists, as well as by several 
practical writers: but it is invariably an eruption of ve- 
sicles; (not of bullas,) and possesses all the other charac- 
teristics of herpes. See belew, ord. vi. gen. 3. 

Sauvages under the head of Erysipelas pestilens (spec. 
5) arranges the fatal epidemic disease, which prevailed 
extensively in the early and dark ages, as the sequel of 
war and famine, and which has received a variety of de- 
nominations; such as ignis sacer, ignis S li Antonii, mal 
des ardens, ergot, kriebel krankheit, &c. &c. according 
to its various modifications and degrees of severity, or 
according to the supposed cause of it.f The erysipela- 

* Mr. Pearson, § 331. 

t Sagar has included the varieties of this disease under the gt- 
nus Necrosis, of which he thus details the symptoms: " Est partis 
mors lenta, sine praevio tumore, mollitie, et dissolutione foetid^, 
cum dolore ardente ordinario et stupore, quae sequitur exsiccatio 
partis, indu ratio, nigredo, et mumia : difTert a gangraena. in eo, 






ERYSIPELAS. 181 

tous redness, however, followed by the dry gangrene, 
which often destroyed the limbs joint by joint, was only 
one of the forms or stages of that disease; as the con- 
tracted and palsied state of the limbs, to which the an- 
cients gave the name of scelotyrbe* constituted another. 
Instead of originating from eating rye affected with the 
ergot, as was supposed in France;! or barley with which 
the raphanns was mixed, as was imagined in Sweden ;J 
the disease was, doubtless, the result of deficient nour- 
ishment, — a severe land-scurvy, which was a great 
scourge of the ancient world, and often denominated 
pestilence.^ The name of St. Anthony seems to have 

quod lentius procedat, cum dolore rodente et stupore, et in mu- 
miam abeat ; gangraena contra mollescai, phlyctaenas elevet, pu- 
trescat, foeteat, atque cito decurrat." Syst. Morbor. cl. iii. ord. 
vii. gen. 42. He describes five species ; and of the fourth efiide- 
mica } he says, " Apud Flandros regnavit haec Necrossis 1749-50, 
spasmi artuum cum doloribus vagis; post 2 vel 3 septimanas 
stupor, fremitus obscurus, artus cum frigore glaciali, contracturis, 
et anaesthesia ; tandem livor partis, nigredo, flavedo, phlyctsenae, 
et siccissima mumia." 

* See Plin. Nat. Hist. lib. xxv. cap. 3. 

t See an able history of the ergot, in the Mem. de la Soc. Roy. 
de Medecine de Paris, torn. i. p. 260, by MM. Jussieu, Paulet, 
Saillant, and the Abbe Tessier. — See also the Philos. Trans, volt 
Iv. p. 118. An interesting account of the kriebel krankheit, 
which was endemic in Hessia and Westphalia during a season of 
dearth in 1 597, is preserved by Greg. Horst. in Oper. lib. viii. 
obs. 22. torn. ii. 

| See Linnasas, Amoenit. Academ. vol. v. 

§ Several instances of pestilence mentioned by Livy appear t© 
s 



138 BULLiE. 

been first associated with, an epidemic disease of this 
kind, which prevailed in Dauphine about the end of the 
twelfth century. An abbey, dedicated to that saint, had 
recently been founded at Vienne, in that province, where 
his bones were deposited; and it was a popular opinion, 
in that and the succeeding century, that all the patients 
who were conveyed to this abbey were cured in the 
space of seven or nine days:* a circumstance, which the 
amply supply of food in those religious houses may pro- 
bably satisfactorily explain. It would be foreign to my 
purpose to pursue the subject here, 



II. PEMPHIGUS. 
There is probably no such fever, as that which has 
been described by a few continental physicians, under 
the titles of fcbris vesicularis, ampullosa, or bullosa, 
and to which Sauvages applied the term Pemphigus.f 
Subsequent nosologists have given definitions of the 
disease, upon the same authority, as an idiopathic, con- 
tagious, and malignant fever, in the course of which 

have been of this kind. Indeed the learned Heyne observes : 
u Nobis manifestum videtur, ne ullam quidem inter Romanos pes- 
tilentiam memorari, quae pro fiestilentid firofirie dicta haberi pos- 
sit," 8cc. (Opusc. Academ. iii. p. 113) 

* Mezeray, Abtege Chronologique. See the articles Ergot, 
and Ignis Sacer, ir Dr. Rees's Cyclopaedia. 

t From irtftpigt bulla, jihlyetcna. See his Nbsol. Method, class. 
iii. gen. 5. 



PEMPHIGUS. \%B 

phlyctasnae or vesications, of the size of a filbert, with 
an inflamed base, appear in .succession on different 
parts of the surface of the body, and sometimes in the 
mouth.* But Dr. Cullen justly expressed his doubts of 
the accuracy of the original writers. The case related 
by Seliger,f on which Suavages founds his first species, 
Pemphigus major, is worthy of little attention, and was 
perhaps, as Dr. Willan suggests, a case of erysipelas, with 
some incidental variation. The account of the epidemic 
at Prague, mentioned by Thierry ,| which is the proto- 
type of the Pemphigus castrensis (spec. 2) of Suavages, is 
not entitled to credit, as Dr. Cullen remarks, in some of 
its circumstances: the bullae are supposed by Dr. Willan 
to have been symptomatic of severe typhus, or of pesti- 
lential fever, in the same manner as Dr. Hodges describ- 
ed those appearances in the plague of 1666, and as they 
are occasionally seen, intermixed with petechias and 
vibices, or with patches of erythema fugax (see page 
119,) in typhoid fevers. Again, as to the Pemphigus 
Helveticus (spec. 3) of Suavages, which is borrowed 

* Dr. Cullen defines Pemphigus, " Typhus contagiosa; primo, 
secundo, vel tertio morbi die, in variis partibus vesiculse, avellanae 
magnitudine, per plures dies manentes, tandem ichorem tenuem 
fundentes." Nosol. Meth. gen. xxxiv. — Linnaeus, who has de- 
signated the disease by the barbarous term Morta, characterizes it 
as "Febris diaria, malignissima, funestissima," Gen. Morbor, 
class, i. gen. 1. 

tSee Ephem. Acad. Nat. Cur. dec. i. ann. viii. obs. 56.— AIs© 
Delius, Amcenit. Medicse, referred to by Suavages. 

% See his Medecine Experimental, p. 134. Par. 1755, 



140 BVLhM. 

from the description of Dr. Langhans,* Dr. Cullen is of 
opinion that the disease was the cynanche maligna; and 
Dr. Frank viewed it in the same light, referring it to scar* 
latina anginosa.f Dr. Willan, who points out the unsatis- 
factory nature of the history given by Langhans, inde- 
pendently of the contradictions which it contains, pro- 
poses a query, whether the disease was not rather 
endemic, than epidemic or contagious, and referable to 
some local cause, like the ergot, Mai des Ardens, &c, 
before alluded to. 

In a word, this conclusion seems to be deducible from 
an examination of these slight and imperfect histories of 
the subject, that the notion of an idiopathic contagious 
fever, terminating in a critical eruption of buMae, has 
been founded in error. All the cases of phlyctaenag, 
which have been related by authors, are therefore re- 
ferable either to typhoid fevers, malignant dysen- 
tery, &c. in which they are accidental and symptoma- 

* In the Acta Helvetica, vol. ii. p. 260. 

t " Quero helveticum alii dixerunt pemphigum, hie ad scarla- 
tina speciem ulcerosa pertinere videtur." lib. iii. p. 253. Dr. Frank 
himself, however, is the author of a singular confusion in regard to 
the genus pemphigus. He divides it into two species; the first of 
which, P. amfllior, includes the eruptions of bullae, which he deems 
in all cases symptomatic of gastric or nervous fevers, or of a chronic 
nature, without any fever; and the second, P. variolodes, which is 
the chicken-pox ; and which he again subdivides into vesicularis 
(the true chicken or swine pox,) and solidcscens (the acuminated, 
warty, dry, hornpock,) which is, in fact, smallpox. 



PEMPHIGUS. 141 

tic;* or to the following genus, pompholyx, in which they 
are unconnected with fever. 

Dr. Willan mentions a Pemphigus hifantilis, of which 
he had seen a few cases in infants, generally soon after 
birth, and which he considered as analogous to the 
erysipelas, which occurs at the same period, and as ori- 
ginating from the same causes. It commonly affected 
weak and emaciated infants, with a dry shrivelled 
skin, and proved fatal in a few days, from the compli- 
cated distress arising from pain, loss of sleep, and violent 
fever. The vesications, which were at first small and 
transparent, became large, oblong, and of a purplish hue, 
and finally turbid, and were surrounded by a livid red 
border. After breaking, they left ulcerations, which 
spread beyond their original limits, and became extreme- 
ly painful.f 

* Such was the Pemphigus Indicus (spec. 4) of Sauvages, taken 
from a single case mentioned by Bontius. — The swine-pox, however, 
seems to have been described by mistake under the title of Pem- 
phigus, by Mr. R. B.' Blagden, in the Med. Facts and Observations, 
vol, L p. 205. 

t Consistently with the opinion that all these bullae are symp- 
tomatic, and that the existence of a peculiar eruptive fever, cha- 
racterized by such vesications, is imaginary, this infantile disease 
should, I conceive, have been referred to Pompholyx, since it ap- 
pears to differ from the Pompholyx benignus of infants, only in 
being connected with a severe and fatal marasmus, instead of the 
irritation of dentition. 



142 BULLAE 

III. POMPHOLYX. 
To an eruption of bullae, appearing " without any 
inflammation around them, and without fever," and 
therefore differing most materially from the pemphigus 
described by nosologists, Dr. Willan applied the appel- 
lation of Pompholyx,* of which he has described three 
varieties. 

1. The Pompholyx benignus exhibits a succession of 
transparent bullae about the size of a pea, or sometimes 
of a hazel nut, which break in three or four days, dis- 
charge their lymph, and soon heal. They appear 
chiefly on the face, neck, and extremities; and occur in 
boys in hot weather, in infants during dentition, and in 
young persons of irritable habit from eating acrid vege- 
table substances, or from swallowing a few grains of 
mercury. 

2. The Pompholyx diutinus (Plate XXXIII.) is a 
tedious and painful disorder, and is usually preceded for 
some weeks by languor and lassitude, headache, sickness, 
and pains in the limbs. Numerous red pimple-like ele- 

* Foesius observes (CEconom. Hippoc. ad voc. vronQot) that 
Hippocrates uses that word to denote wheals, or those eminences 
which resemble the eruption produced by nettles, (lib. ii. Ileps 
n«tav) and that cr«,«,0eAt/yfs are the bubbles of air, which appear 
upon water: but that Galen explains the fwm/ihi, as eminences of 
the cuticle, containing a fluid ; in exegeei, lib. ii. dc Mulier.— - 
See also Gorraeus, Def. Med, 



-fOMPHOLYX. 143 

?atio»8 of the cuticle appear, with a sensation of tingling, 
which are presently raised into transparent vesications, 
that become as large as a pea within twenty-four hours, 
and, if not broken, afterwards attain the size of a walnut 
If they are rubbed off prematurely, the excoriated sur- 
face is sore and inflamed, and does not readily heal. 
The bullae continue to arise in succession on different 
parts of the body, and even re-appear on the parts first 
affected, in some cases for several weeks so that the 
whole number of bulla? is very great; and when the ex- 
coriations are thus multiplied, a slight febrile paroxysm 
occurs every night, and the patient suffers much from 
the irritation, and from want of sleep. 

This disease chiefly affects persons of debilitated 
habits, and is very severe in the aged. It seems to ori- 
ginate under different conditions of the body, but 
often after continued fatigue and anxiety, with low diet; 
sometimes from intemperance; and not unfrequently 
it is connected with anasarca, or general dropsy, with 
scurvy, Purpura, and other states of the constitution, in 
which the powers of the cutaneous circulation are feeble. 
It has, in some instances, appeared after profuse sweat- 
ing, during which cold liquors were copiously swal- 
lowed, in common with several other forms of chronic 
cutaneous disease. In the fevers in which it has been 
observed, it was obviously symptomatic; for it has not 
only occurred at various periods, and varied much in 
its duration, but has accompanied fevers of the con- 



144 BULUE: 

tinued, remittent, and intermittent type, as well as ar- 
thritic, and other secondary fevers.* 

It is sufficiently clear, from the statements of the 
writers just referred to, that the Pompholyx is never 
communicated by contagion; and that the fluid con- 
tained in the vesicles is not ichorous, but a bland 
lymph,f resembling that which is poured into the ven- 
tricles of the brain in hydrocephalus. In several of 
the persons, whose cases are recorded, the disease oc- 
curred more than once. The Pompholyx is most 
troublesome and obstinate in old persons, in whom the 
transparent bullae sometimes equal the size of a turkey's 
egg, while others of a smaller size are intermixed with 
them, which appear dark and livid. When broken, 
they leave a black excoriated surface, which sometimes 
ulcerates. 



* Many cases illustrative of these observations are on record , 
especially those related, under the appellation of Pemphigus, by 
Mr. Gaitskell, and Mr. Upton, in the Memoirs of the Medical 
Society of London, vol. iv. art. i. and vol. iii. appendix ; by Mr. 
Christie, in the Lond. Med. Journal, vol. x. p. 385 (for 1789;) by 
Dr. Stewart, in the Edin. Med. Commentaries, vol. vi. art. 3. p. 79. 
by Dr. Hall, in the Annals of Med. vol. iii. art. ix.; by Mr. Ring, 
in the Lond. Med. Journ. xi p. 235 ; by Dr. Dickson, in the Trans. 
of the Royal Irish Academy, for 1787, and Lond. Med. J. vol. ix. 
p. 309 ; and by B»ng, in the Acta. Reg. Soc. Med. Hauniensis; 
vol. i. p. 8, Sec. See also Frank, De curanc 1 . Horn. Morbis, lib. iii. 
p. 263. Sennert. de Scorbuto, cap. v. § 59. 

I Mr. Gaitskell not only proved this by analysis, but by inocu- 
lating himself with it with perfect impunity. 



POMPHOLYX. 145 

The warm bath, used every second day, was consi- 
dered by Dr. Willan as the most active palliative, and 
the best remedy. I think I have seen the decoction of 
cinchona, with cordials and diuretics, of considerable 
advantage in these cases, especially when the eruption 
was combined with anasarca. In young persons, in 
whom the Pompholyx is seldom severe, these remedies 
are affirmed by Dr. Willan to be successful within two 
or three weeks; but the warm bath seems to increase 
both the tingling in the skin, and the number of the 
vesications, in these patients,* 

3. The Pompholyx solitarius is a rare form of the 
disease, which seems to affect only women. One large 
vesication usually appears in the night, after a sensation 
of tingling in the skin, and rapidly distends itself, so 
as to contain sometimes a tea-cupful of lymph: within 
forty-eight hours it breaks, discharging its fluid, and 
leaving a superficial ulceration. Near this another 
bulla arises in a day or two, and goes through the same 

* The warm bath sometimes aggravates the disease, even in the 
aged, as I lately had an opportunity of witnessing in an old laclyof 
SO. In this case, however, the bullce, of which eight or ten arose 
daily for several months, were surrounded by an extensive erythe- 
matous inflammation, and there was a considerable tendency to 
the febrile state. A single immersion in the warm bath excited a 
violent fever ; and bark, sarsaparilla, and other tonics, produced a 
similar effect. She ultimately recovered, under a light and refri- 
gerant diet and regimes 

T 



146 BULLAE: 

course; and it is sometimes followed, in like manner, 
by two or three others in succession; so that the whole 
duration shall be eight or ten days. Cinchona inter- 
nally, and linseed poultices, followed by light dressings 
to the sores externally, were employed with advantage 
in three cases seen by Dr. Willan, 



147 

Order V. 

PUSTULE. 

Pustules* originate from an inflammation of the 
skin, and the consequent partial effusion of purulent 
matter under the cuticle, by which the latter is elevated 
into small circumscribed tumours (Def. 5.) Sometimes 
several of these elevations arise upon a common in- 
flamed surface; but most frequently the inflammation of 
the base of each is distinct and circumscribed. They 
often terminate in a scabby incrustation, varying in 

* Although it seems obvious, that the origin of this term was 
deduced from the purulent contents of the eruption (quasi, pus 
tune,;) yet the best ancient authority sanctions the common inde- 
finite and unlimited use of it. For Celsus applies it to every eleva- 
tion of the cuticle, including even wheals and papulae, " quae ex 
urtica, vel ex sudore nascuntur ;" and he deems it synonymous 
with s^etvSufAct of the Greeks, which was in fact the general term 
for every species of eruption, (Celsus de Med. lib. v. cap. 28, § 
15. — See above, page 55, note.) The Greek physicians appear 
to have comprehended both pustules and vesicles under the term 
pxvKTxivui, which their translators have rendered by the word, 
pustules; and in this double sense the latter has also been gener- 
ally used. Some discriminating writers, however, have correctly 
appropriated it to suppurating eruptions. " Pustularum nimirum 
conditio," says Prof. Arnemann, " exigit, ut in apice sufifiurentur 
vel in pus abeant." (Commentar. de Aphthis, Gott. 1787, § 2, 
See also Ljnn. Gen. Morb, class xi, ord. 4.— -Sagar, elass i. 
ord. 2.) 



148 PUSTULE: 

hardness according to the various tenacity of the con- 
tained fluid; and sometimes in superficial ulceration, 
The five genera of pustular diseases, comprehended in 
this order, have nothing in common in their character, 
except the appearance of pustules in some stage of their 
progress: for some are contagious, and others not; some 
are acute, and others chronic. 



I. IMPETIGO, 
HUMID OR RUNNING TETTER. 

This eruption is characterized by the appearance of 
the small pustules, denominated Psydracia (Def. 5. b), 
It is not accompanied by fever, not contagious, nor 
communicable by inoculation. It chiefly occurs on the 
extremities, and under the following forms.* 

1. The Impetigo Jigarata (Plate XXXIV.) is the 
most common variety of the moist tetter. It appears is 
circumscribed patches, of various figure and magnitude, 
which are usually smaller and more circular on the 

* Celsus has described four species of Impetigo, the first of 
which is a pustular disease, terminating in excoriation, and corres- 
ponds with the affections described in the text. His other varieties 
seem to include some of the more violent forms of psoriasis, or 
lepra. See the 28th chapter of his 5th book, § 17. 

The ulcerated psora tye/px eXx-a^ns) of the Greeks was appa- 
rently the same affection with the Impetigo of Celsus. 



IMPETIGO. 149 

upper, and larger, oval, and irregular, on the lower ex- 
tremities. The patches consist at first of clusters of the 
yellow psydracious pustules, set close together and sur- 
rounded by a slight inflammatory border; the whole 
being somewhat raised, but the pustules not very promi- 
nent or acuminated. In a few days the pustules break, 
and discharge their fluid; the surface becomes red and 
excoriated, shining as if it were stretched, but exhibit- 
ing numerous minute pores, from which a considerable 
ichorous discharge is poured out, accompanied with 
much troublesome itching, heat, and smarting. The 
discharge soon concretes partially into thin yellowish or 
greenish scabs; but still continues to ooze from under 
the scab, which it forms. In the course of three or 
four weeks, as the quantity of the discharge diminishes, 
the scabs dry and fall off, leaving the surface of the cu- 
ticle red, rough, and somewhat thickened, and at the 
same time extremely brittle, and liable to crack and to 
be excoriated; so that the ichorous discharge and scab- 
bing are easily reproduced, and the disease is often thus 
much prolonged in its duration. Occasionally fresh 
crops of the psydracious pustules reappear, as at the 
commencement; and the whole course of the eruption 
is repeated. 

When the Impetigo figurata is beginning to heal, the^ 
patches undergo a process somewhat similar to that 
which takes place in the lepra vulgaris. The amend- 
ment commences at the centre of the patch, which first 
subsides, leaving the border elevated: at length this also 



150 



PUSTULJE: 



disappears; but the cuticle, which was the seat of the 
patch, remains for some weeks red, shining, and tender. 

But though this is the most usual and regular, it is 
by no means the uniform progress of Impetigo. For 
this eruption, like scabies and eczema, varies so much 
in its phenomena, as almost to bid defiance to arrange- 
ment. Sometimes the patches enlarge by the formation 
of successive pustular margins; an exterior circle of 
pustules arising, while the preceding border is drying, 
to be followed by others which go through the same 
course, until the patch attains a considerable extent. 
The area, in the mean time, becomes dry and rough, 
with a scaly or scabby incrustation in its centre.* Some- 
times the papulae of the lichen agrius become pustular, 
or are intermixed with psydracia, as before mentioned; 
and the disease assumes all the characters of Impetigo. 

But the affinity of Impetigo with the vesicular dis- 
eases is manifested by a common variety of it in the 
upper extremities, in which the psydracious pustules are 
intermixed with transparent vesicles, resembling the 

* This impetiginous ring worm bears a considerable resem- 
blance to the herpes circinatus, which spreads by a succession of 
■vesicular borders. A severe form of this tetter occurs in hot cli- 
mates, according to the testimony of physicians who have prac- 
tised there. See Hilary on the Diseases of Barbadoes, p. 352 (2d 
edit). — Towne on the same, chap 8. — Winterbottom's Account of 
Sierra Leone, vol. ii. chap. 9. — Probably it is this form of Impe- 
tigo, which Bontius mentions, as a most distressing disease in 
India, where it is called by the natives coura/i. (De Med. Indo- 
rum, cap. 17.) 



IMPETIGO. 151 

pustules in size and form. Where this intermixture 
occurs, the disease is much more troublesome, from the 
extreme irritation, itching, smarting, and heat, which 
accompany it; and much more tedious and difficult,of 
cure. It takes place chiefly on the hand, about the 
knuckles and sides of the fingers, or on the wrist; and 
the space between the metacarpal bones of the fore- 
finger and thumb is usually the seat of one of the 
blotches. The vesicles are slower in their progress 
than the psydracia: they remain many days transparent, 
but not much elevated, the cuticle over them being thick 
in that situation. — When they break, an acrid ichor is 
discharged, which produces inflamed points where it 
touches the cuticle, and these become vesicles or psy- 
dracia. Each vesicle, thus broken, is not disposed to 
heal; but the cuticle round its base now becomes inflam- 
ed and raised, and discharges a thin ichor, when in any 
degree irritated. The vesicles appear, in slow succes- 
sion, at a little distance from each other and from the 
pustules; and at length an irregular blotch is produced, 
of a red, chopped, and thickened cuticle, interspersed 
with the rising eruptions, little humid ulcers, and chops 
or fissures.* The sense of burning and intense itching, 

* This mixed form of the disease has misled the generality of 
writers to confound it with herpes, under which term it is com- 
monly described. Such is the herpes of Dr. Cullen. "Phlyctse- 
nae, vel ulcuscula plurima, gregalia, serpentia, dysepuleta." No- 
sol, gen. 147. And Prof. Callisen's brief description of herpes, in 
one of its varieties, is an accurate delineation of this Impetigo, 



152 PUSTULvE: 

accompanying especially the first rise of the vesicles, is 
extremely distressing, and is much aggravated by the 
irritation of almost every application that is resorted to. 

2. The Impetigo sparsa (Plate XXXV.) differs from 
the preceding rather in the form, than in the nature and 
progress of the eruption: for, with the exception of the 
indeterminate distribution of the pustules, which are not 
congregated in circumscribed clusters, but dispersed 
without any regular order along the extremities, and 
sometimes about the neck and shoulders, and even on 
the ears and scalp, the foregoing description is applica- 
ble to both species of the disorder. The Impetigo spar- 
sa more frequently occurs in the lower extremities, than 
the former; and is, in that situation, more troublesome 

" Herpes /mstulosus, crustosus, serfiigo, quern constituunt papulae 
pejores conosivae, quae con^estae aream circularem constituunt, 
acute pnngentem, valde pruriginosam, deinde pars ilia tegitur 
crusta cuti fiimiter adglutinata, a transudatione humoris tenuis et 
acris e cute porosa ; ichor, si tangit alias partes, istas simili malo 
defaeclat, unde late serpere solet hoc malum, tamen absque exul- 
ceratione." (Chirurg. Hodiern. § 612.) See also Wiseman's 
Chirurg. Treatises, i. chap. 17, on Herpes. Turner on the Dis. 
of the Skin, chap. v. where herpes and tetter are used as synoni- 
mous terms. — But it is to be recollected that, in this arrangement, 
herpes is appropriated to a purely vesicular disease, which has a 
short and nearly uniform course of ten or twelve days, the vesicles 
of each pate! 1 , becomirg confluent, and at length covered with a 
dry crust. Of this genus the shingles afford the most character- 
zstic examn'e. 






IMPETIGO. 153 

and obstinate. In elderly people, especially of debilita- 
ted habits, the excoriations are liable to pass into deep, 
irregular ulcers, surrounded by a purplish colour, and 
often accompanied with oedema. 

These two forms of Impetigo are not always traced to 
any obvious exciting cause: but they are frequently pre- 
ceded by some derangement of the digestive organs, lan- 
guor, and headache. A predisposition to the disease 
appears to be connected with the sanguine temperament, 
with a thin soft skin, and a relaxed and bloated habit of 
body; or, with the sanguineo-melancholic temperament, 
a spare form, and a thin but harsh skin. Certain sea- 
sons appear to have great influence on the disease, in 
those who are predisposed to it. The I. sparsa, espe- 
cially on the lower extremities, is apt to return with re- 
gularity at the latter end of autumn, and to harass the 
patient during the whole of the winter, but disappears 
in the warm weather: while the I. figurata, affecting the 
upper extremities, is liable to recur in the spring; of 
both which I have witnessed several examples.* The 
accession of the eruption has, in other instances, been 

* In this and some of the preceding circumstances, the accuracy 
of the brief description of Celsus is manifest. The first form of 
Impetigo is that, "quae similitudine scabiem repraesentat ; nam et 
rubet, et durior est, et exulcerata est, et rodit. Distat autem ab ea, 
quae magis exulcerata est, et varis similes pustulas habet, viden- 
turque esse in ea quasi bullulae qusedam, ex quibus interposito 
tempore quasi squamulse solvuntur ; certioribusque haec tempori- 
bus revertitur." 



154 PUSTULE 

ascribed to violent exercise, intemperance, cold, and sud- 
den depressing passions, especially fear and grief.* 

Local tetters are produced by the action of particular 
irritants on the cuticle, which soon disappear, when the 
source of irritation is withdrawn. The affection of the 
hands and fingers, in those #ho work among sugar, 
which is called the grocers itch, is of this nature; and 
similar eruptions are produced on the hands of brick- 
layers, by the acrid stimulus of lime. It is worthy 
of remark, that both the grocer's and the brick- 
layers itch is, in some individuals, a pustular and in others 
a vesicular eruption, referable to the eczema; but in 
neither case contagious, as the popular appellation might 
lead us to suppose. 

Local pustular patches are also the result of the ap- 
plication of the tartrite of antimony to the skin by fric- 
tion, and in some cases of the application of blisters, and 
other stimulating plasters. These pustules are liable to 

* In two gentlemen, whom I lately had occasion to see, affected 
■with Impetigo, the eruption was imputed to great alarm and agi- 
tation of mind. Some of the scaly eruptions also are now and then 
referred to fear and grief, as well as the tubercular elephantiasis. 
See Dr. Tho. fieberden's remarks on the elephantiasis, in Ma- 
deira (Med. Trans, vo!. i. art. 2;) and those of Dr. Joannis on 
that of Martigues (Med. Obs. and Inquir. vol. i. art. 19.) Some 
time ago we witnessed the extraordinary influence of mental alarm 
on the cutaneous circulation, in a poor woman, who became a 
patient of the Public Dispensaiy. A sudden universal anasarca 
followed, in one night, the shock occasioned by the loss of a small 
sum of money, which was all she possessed. (See Edinb. Med. 
and Surg. Journal, vol. v. p. 127. 



IMPETIGO. \5b 

extend considerably beyond the blistered or stimulated 
part, and sometimes continue to arise in succession for 
a fortnight or more; and many of them often assume the 
form of phlyzacia (Def. 5. a,) or of large, protuberant 
pustules, with a hard elevated and inflamed base. Some 
of these even acquire the size of small boils, and suppu- 
rate deeply and slowly, with great pain, and considerable 
restlessness and feverish heat in the night 

The Impetigo figurata and sparsa are sometimes con- 
founded with two contagious diseases of the pustular 
order, porrigo and scabies. The appellation of ring- 
worm, which is popularly given to the oval or circular 
patches of the first, has partly contributed to occasion 
this mistake. They differ, however, from the contagious 
circles of porrigo, inasmuch as they seldom affect chil- 
dren, — occur principally on the extremities, — and do 
not continue to discharge a purulent and glutinous, but, 
after the first eruption, an ichorous humour, — nor do 
they form the thick, soft, and copious scabs of porrigo: 
not to mention the absence of contagion. 

The prevalence of transparent vesicles in the patches 
of Impetigo, may mislead an incautious or inexperienced 
observer into a suspicion that the disease is scabies: but 
the distribution of the eruption in patches, — the copious 
exudation of ichor, — the rough, reddened, and fissured 
cuticle, — the magnitude and slow progress of the vesi- 
cles, — and the heat and smarting which accompany the 
itching, in this form of Impetigo, will serve in general to 
determine the diagnosis. In the strictly purulent form 



156 PUSTULE: 

of scabies, the pustules about the hands arise to a much 
greater magnitude and elevation, than the psydracia, they 
are filled with a thick yellow pus, and are more consider- 
ably inflamed round their base. 

In the incipient state of these two forms of Impetigo, 
it is useful to administer sulphur internally, in such quan- 
tities as not to induce purging; and, if there is much 
irritability or inflammation of the cuticle, a portion of 
nitre or crystals of tartar may be advantageously com- 
bined with it. The Impetigo sparsa commonly yields to 
these medicines, if diligent ablution with tepid water be 
at the same time employed. But when the disease is of 
long standing, it requires a treatment somewhat similar 
to that recommended for inveterate psoriasis; namely, 
the diet drinks, decoctions of sarsaparilla and cin- 
chona, with the fixed alkalis, and antimonials. The 
mercurial alteratives, however, in this affection, are of 
essential assistance to this plan of cure; such as small 
doses of cinnabar, the hydrargyria cum creta, or the 
pill of Dr. Plummer. 

The external applications adapted to these forms of 
Impetigo, especially to the figured species, are the mild 
desiccative unguents: for, in the majority of cases, the 
irritable surface of the tetter will not bear stimulants 
with impunity. When the discharge is considerable, 
the ointments prepared with the oxide of zinc, alone, or 
united with saturnine ointment, or with the white pre- 
cipitated oxide of mercury, are the most efficacious, in 
allaying the inflammatory condition of the excoriated 



IMPETIGO. 157 

surface, and in reducing the quantity of the discharge. 
When there is less of this irritability and exudation, the 
ointment of the nitrate of mercury, much diluted, as 
with five or six parts of simple ointment will be benefi- 
cial. From the too active employment of this unguent, 
and still more of that of the nitrico-oxide of mercury, 
by practitioners unacquainted with the character of the 
disorder, a great aggravation of the eruption and of the 
sufferings of the patient is sometimes occasioned. 

In some instances, indeed, the skin, under this impe- 
tiginous affection, is peculiarly sensible to the stimulus 
of mercury, whether employed internally or externally. 
I think I have observed this circumstance most frequent- 
ly in a few cases, which were the sequelae of lichen, 
But the most irritable of all the varieties of Impetigo, 
are those in which vesicles abound; in some of which 
the zinc, and saturnine applications, and even simple 
lard, occasion an aggravation of the symptoms. In these 
cases, it is particularly necessary to keep the parts co- 
vered, with a view to avoid the effects of friction from 
the clothes, as well as of heat, and of cold; to wash the 
surface daily with some emollient fluid, such as milk 
and water, or an infusion of bran; to interdict the use 
of soap; and to besmear the parts with cream, or an 
emulsion of almonds. A lotion prepared by boiling mal- 
low, digitalis, and poppy-heads has been found service- 
able, where the parts were very painful. In many cases, 
however, the stiffness, which ensues upon the speedy 
drying of these lotions, renders it impossible to use them. 



158 PUSTULJE: 

and it is necessary to cover the part lightly with dry 
lint only, or to interpose between it and the diseased 
surface a sprinkling of the oxide of zinc. 

In the drier, and less irritable forms of the Impetigo, 
the use of the waters of Harrowgate is the most effectual 
remedy, and likewise the best preventive of its returns: 
under the same circumstances, the warm sea-water bath, 
followed by a course of bathing in the open sea, is pro- 
ductive of great benefit. 

3. Impetigo erysipelatodes. This form of the dis- 
ease, in its commencement, presents nearly the ordinary 
appearances of erysipelas; namely, a redness and puffy 
swelling of the upper part of the face, with oedema of 
the eyelids; and is accompanied with slight febrile 
symptoms for the space of two or three days. But on a 
minute examination, the surface, instead of the smooth 
polish of erysipelas, is found to exhibit a slight inequali- 
ty, as if it were obscurely papulated; and, in a day or 
two, the true character of the disease is manifested, by 
the eruption of numerous psydracious pustules, over the 
inflamed and tumid skin, instead of the large irregular 
bullce of erysipelas. These pustules first appear below 
the eyes, but soon cover the greater part of the face, 
and sometimes extend to the neck and breast: they are 
accompanied with a distressing sense of heat, smarting, 
and itching. When they break, they discharge a hot 
and acrid fluid, which adds to the irritation and excoria- 
tion of the surface. In this painful condition the face 



IMPETIGO. 159 

remain^ for ten days or a fortnight, when the discharge 
begins to diminish, and to concrete into thin yellowish 
scabs. But on the interstices between the scabs, fresh 
pustules arise at intervals, with renewed heat and pain, 
and subsequently discharge, ulcerate, and form scabs, 
like the former. The disease continues thus severe and 
troublesome for an uncertain period, from one to two or 
three months; and ultimately leaves the cuticle in the 
same dry, red, and brittle state, which remains after the 
other forms of Impetigo. The constitution is scarcely 
disturbed during the progress of this disease, and is much 
less disordered in the outset than in erysipelas. Its af- 
finity with Impetigo has been further evinced, in some 
cases which I have seen, by the occurrence of the other 
forms of the eruption on the extremities, during its 
course; occasionally, indeed, extending over the whole 
surface, a capite ad calcem. 

In the commencement of the disease, purgative me- 
dicines, with the antiphlogistic regimen, afford great al- 
leviation to the symptoms; but when the copious exuda- 
tion and scabbing take place, the cinchona, in consi- 
derable doses, alone, or with the sarsaparilla, or mineral 
acids, is administered with the greatest benefit. The 
same local treatment is requisite, as in the other forms 
of the eruption; viz. tepid ablution, with emollient li- 
quids; the application of the mildest ointments; and the 
use of sea-bathing, or of the sulphureous waters, in its 
decline. 



160 PUSTULE: 

4. Impetigo scabida. (Plate XXXVI.) In this more 
rare and severe form of the disease, one or more of the 
limbs becomes encased in a thick, yellowish, scabby 
crust, not unlike the bark of a tree, which is accompa- 
nied with a disagreeable heat and itching, and renders 
the motion of the affected limbs difficult and painful. 
This crust is the result of the concretion of an acrimo- 
nious humour, which is discharged in great abundance 
from numerous psydracious pustules, as they successive- 
ly form, break, and ulcerate over the surface of the 
limb. The concretion commences about the third or 
fourth week, when the discharge begins to abate, and 
invests the whole of the arm from the elbow to the wrist, 
or the leg from the knee to the ancle.* After some time 
longer, the scabby coating is divided by large cracks or 
fissures, from which a thin ichor exudes, and concretes 
into additional layers of scabs. If any portion of the 
scab be removed, the excoriated surface pours out its 
fluid again, and fills up the space with a new concretion. 
In the lower extremities, the disease is most severe and 
obstinate, is ultimately conjoined with anasarca, and often 

*Sauvages observes that this affection is called dartres encrou- 
tees Ly the French ; but he describes it under the appellation of le- 
jira herpetica. " Cognoscitur ex herpetibus crustaceis, squamo- 
us, albis, hyeme majoribus, et suppurantibus ; noctu intolerabili- 
ter prurientibus : brachia ambo usque ad carpum, ambo femora 
tibiasque usque ad pedes, quandoque tegentibus; scalptu cruen- 
tatur haec lepra; poplites et cubiti vix flecti possunt : pnecesse- 
runt non raro tineae malignae." Class, x. gen. xxvii. spec. 7. 






IMPETIGO. 161 

produces severe ulceration. The incrustation sometimes 
extends to the fingers and toes, and destroys the nails; 
and, as in other similar instances, the new ones are 
thick, notched, and irregular.* 

The I. scabida requires the same internal medicines, 
which have been recommended for the inveterate forms 
of the preceding varieties, especially the sulphureous 
waters. The chief peculiarity of its treatment consists 
in clearing the surface of its incrustation, and correct- 
ing the morbid action of the superficial vessels. The 
thick scab can only be softened and gradually removed, 
by perseverance in the application of the steam of warm 
water to it, for a short time, daily. Those parts of the 
surface, which are thus cleared, must be covered with 
soft linen, after tepid ablution, twice a day; and some 
of the unguentum zinci, or a much diluted ointment of 
nitrate of mercury, with common cerate, (containing, 
for example, a fourth or fifth part of the mercurial,) or 
simply the oxide of zinc, or calamine in powder, must 
be interposed. 

5. The Impetigo rodens is a rare, but intractable 
species of the disease, probably of a cancerous nature, 
in which the cellular membrane is affected, as well as 
the skin, and seems to shrink away, as the ulceration 
and discharge go on. The disorder commences with a 
cluster of pustules, sometimes intermixed with vesicles, 

* See lepra) above, p. 27. 
x 



162 PUSTULE 

which soon break, and discharge for a long period oi 
time an acrid humour, from open pores or from under 
scabs; and the skin and cellular texture are slowly, but 
deeply and extensively, corroded, with extreme irrita- 
tion and pain, which are only to be alleviated by large 
doses of opium. The disease commonly begins on the 
side of the chest or trunk of the body, and gradually 
extends itself. I have not seen any instance of this 
disease, which is said to have always terminated fatally, 
and to have been benefited by no medicine, either ex- 
ternal or internal, which had been employed. 



II. PORRIGO. 
RINGWORM OF THE SCALP, SCALI/d HEAD, ETC. 

The Porrigo* is a contagious disease, principally 

* This term is adopted, as a generic appellation, nearly in the 
oame sense in which it was used by Celsus, who included the 
moist and ulcerating, as well as the dry and furfuraceous eruptions 
of the scalp, under this denomination. (De Med. liv. vi. cap. 3.) 
The word tinea is employed in the same generic sense by Sau- 
vages ; but being a term of no authority, and probably of Arabic 
origin, it is properly superseded by the classical appellation. Nu- 
merous writers, ancient and modern, have designated the varieties 
of the disease by distinct names ; such as crusta lactea, alopecia, 
pityriasis, favi, achores, scabies capitis, &c. : but the most intelli- 
gent observers have pointed out the identity of the nature and 
causes of these various eruptions. See Sennert. de Morb. Infant. 
p. ii. cap. 4 ; and Pract, lib. v. p. iii. § ii. cap. 4. — Heister, Chi- 



P0RRIG0. 163 

characterized by an eruption of the pustules, denomi- 
nated favi and achores (Def. 5. c, d,) unaccompanied 
by fever. The several appearances which the disorder 
assumes are reducible to five or six specific forms.* 

1. The Porrigo larvalisj (Plate XXXVII.) or Crus- 
ta lactea of authors, is almost exclusively a disease of 
infancy. It commonly appears first on the forehead 
and cheeks, in an eruption of numerous minute and 
whitish achores, which are crowded together, upon a red 
surface. These pustules soon break, and discharge a 
viscid fluid, which concretes into thin yellowish or 
greenish scabs. As the pustular patches spread, the dis- 
charge is renewed, and continues also from beneath the 
scabs, increasing their thickness and extent, until the 
forehead, cheeks, and even the whole face, become en- 
veloped, as by a mask (whence the epithet larvalis,) the 
eyelids and nose alone remaining exempt from the in- 

rurg. p. i. lib. 5. cap. x. — -Tilingius, Lilium curiosum, cap. 17 — ° 
Vogel, de cognos. et cur. Horn. Morb. class, viii. § 713. — Stoll, 
Rat. Med. i. 49. 

* It must be remarked, however, that the first species appears 
to differ essentially from the rest ; inasmuch as it arises independ- 
ently of contagion, is perhaps never communicated by contact, and 
is connected principally with the period of lactation. In some re- 
spects it bears an affinity with impetigo. 

t The « teigne muqueuse" of Alibert, and pretty well deline- 
ated in his 5th plate.— Liv. i. 



164 PUSTULE: 

crustation.* The eruption is liable, however, to consi- 
derable variation in its course; the discharge being some- 
times profuse, and the surface red and excoriated, — and 
at other times, scarcely perceptible, so that the surface 
remains covered with a dry and brown scab. When the 
scab ultimately falls off, and ceases to be renewed, a red, 
elevated, and tender cuticle, marked with deep lines, 
and exfoliating several times, is left behind; differing 
from that which succeeds to impetigo, inasmuch as it 
does not crack into deep fissures. 

Smaller patches of the disease not unfrequently ap- 
pear about the neck and breast, and sometimes on the 
extremities: and the ears and scalp are usually affected 
in the course of its progress. In general the health of 
the child is not materially affected, especially when the 
eruption does not appear in the early period of lactation; 
but it is always accompanied with considerable itching 
and irritation, which, in young infants, often greatly di- 
minish the natural sleep, and disturb the digestion. 
Whence much debility sometimes ensues; the eyes and 
eyelids become inflamed, and purulent discharges take 
place from them and from the ears; the parotid and 
subsequently the mesenteric glands become inflamed; 
and marasmus, with diarrhoea and hectic, cut off the 
patient 

Most commonly, however, the disease terminates 

* " Imo quandoque fiontem occupant, et lotam faciero, excep- 
tis palpebris, larva tegunt." Plenck, p. 77. 



P0RRIG0, 165 

favourably, though its duration is often long and un- 
certain. It sometimes suddenly puts on the appearance 
of cessation, and afterwards returns with severity. 
Sometimes it disappears spontaneously soon after wean- 
ing, or after the cutting of the first teeth; and some- 
times it will continue from two or three months to a 
year and a half, or even longer. It is remarkable, how- 
ever, that, whatever 'excoriation may be produced, no 
permanent deformity ensues. Dr. Strack has affirmed, 
that when the disease is about to terminate, the urine 
of the patient acquires the odour of the urine of cats; 
and that, when the usual odour remains unchanged, the 
disease will generally be of long continuance.* 

In the commencement of the Porrigo larvalis, while 
the discharge is copious and acrid, it is necessary to 
clear the surface two or three times a day by careful 
ablution with some tepid and mild fluid, as milk and 
water, thin gruel, or a decoction of bran; and to apply 
a mild ointment, such as the unguentum zinci, or a 
combination of this with a saturnine cerate. The latter 
will be useful to obviate excoriation, while the surface 
remains red and tender, after the discharge has 
ceased. 

The removal of the disease is much accelerated by 
the use of alterative doses of mercurial purgatives, (es- 
pecially where the biliary secretion is defective, the 



* See his Dis. de Crusta Iactea infantum, et ejusdem specifico 
^emedio: — alsoLond. Med. Journal, vol. ii. p. 187. 



166 PUSTUUE: 

abdomen tumid, or the mesenteric glands enlarged,) 
which should be continued for three weeks or longer, 
according to circumstances. Small doses of the sub- 
muriate may be given twice a day, alone, or in combi- 
nation with soda and a testaceous powder; or, if the 
bowels are very irritable, the hydrargyrus cum creta, 
or the cinereous oxide, may be substituted. But if the 
general health appear sound, the inflammatory condi- 
tion of the skin, and the profuse exudation, may be al- 
leviated by the internal use of soda, with precipitated 
sulphur, or with the testacea. 

When the state of irritation is removed, and the 
crusts are dry and falling off, the unguentum hydr. 
nitrati, much diluted, may be applied with advantage. 
And now some gentle tonic should be administered; 
such as the decoction of cinchona, or the chalybeates, 
(which are more readily taken by children,) especially 
the saturated solution of the tartrite, or the vinem ferri. 

I cannot speak from experience respecting the medi- 
cine recommended as a specific by Dr. Strack; namely, 
a decoction of the leaves of the viola tricolor of Lin- 
nseus, in milk.* In the course of the first week, this 
medicine is said to increase the eruption considerably; 
but at the same time the urine acquires the smell above 
mentioned, and, at the end of a fortnight, the crusts 



* He prescribes a handful of the fresh, or half a drachm of the 
dried leaves, to be boiled in half a pint of cow's milk, and the 
whole to be taken night and morning. 






PORRIGO. 167 

begin to fall off, and the skin underneath appears clean. 
Prof. Selle, however, has affirmed, that this plant is 
either noxious, in this complaint, or wholly inert* 

2. Porrigo furfurans.j (Plate XXXVIII.) In this 
form of the disease, which commences with an eruption 
of small achores, the discharge from the pustules is 
small in quantity, and the excoriation slight; the hu- 
mour, therefore, soon concretes, and separates in innu- 
merable thin laminated scabs, or scale-like exfoliations. 
At irregular periods, the pustules re-appear, and the 

* Medicina Clinica, i. 185. 

f This is the tinea furfuracea of Sennertus, the tinea fiorri' 
ginosa of Astruc and Sauvages, the Porrigo furfuracea of Plenck, 
and the " teigne furjurace'e" of Alibert. (Sennert: de Curat. In- 
fant, p. ii. cap. 4. — Sauvages, Nos. Method, class, x. gen. xxix. 
spec. 6. Plenck, Doctr. de Morb. cut. class, vii. Alibert, plate 3, 
where it is well represented. It may be observed that the " T. 
amfantacee" of this writer (plate 4) appears to be a variety of P. 
furfurans.) It is, in fact, to afurfuraceous disease alone that the 
translators of the Greek physicians, and many modern Latin 
writers, apply the term porrigo, deeming it synonymous with the 
Greek Trnvpietris. From the authority of Celsus, however, it is 
obvious that this is a misapplication of the term ; and it is im- 
proper to comprehend the simple dandriff, and the contagious 
scall, under the same generic appellation. See Pityriasis, above, 
page 45, note. Plenck, though applying the term to both, marks 
the distinction, calling the contagious disease, porrigo furfuracea, 
seu vera, — and the other P. farinosa, seu spuria, which he con- 
siders as a mere accumulation of the secretion from the sebaeeous 
glands. 



168 PUSTULE: 

discharge being renewed, the eruption becomes moist; 
but it soon dries again and exfoliates. It is attended 
with a good deal of itching, and some soreness of the 
scalp, to which the disease is confined; and the hair, 
which partially falls off, becomes thin, less strong in its 
texture, and sometimes lighter in its colour. Occasion- 
ally the glands of the neck are swelled and painful. 

The P. furfurans occurs principally in adults, espe- 
cially in females, in whom it is not always easily dis- 
tinguished from the scaly diseases, pityriasis, psoriasis, 
or lepra, affecting the capillitium. The circumstances 
just enumerated, however, will serve to establish the 
diagnosis: as in those diseases, no pustules appear in 
the beginning, — there is no moisture or ulceration, — 
and the hair is not detached, nor changed in texture and 
colour; — neither are they communicable by contact. 

In the treatment of the P. furfurans, it is absolutely 
necessary to keep the scalp closely shaven. The branny 
scabs should then be removed by gentle washing, with 
some mild soap and water, twice a day ; and an oil-silk 
cap should be worn, partly for the purpose of keeping 
the surface moist as well as warm, and partly for the 
convenience of retaining an ointment in contact with it. 

The nature of the ointments employed in this, as in 
the other species of Porrigo, must be varied, according 
to the period of the disease, and the irritability of the 
part affected. In the commencement of the eruption, 
when the surface is moist, tender, and somewhat in- 



PORRIGO. 169 

flamed, the zinc ointment should be applied; or, what 
has been said to be more beneficial, an ointment pre- 
pared with the cocculus Indicus, in the proportion of two 
drachms of the powdered berry to an ounce of lard. 
But when the scalp becomes dry and inirritable, in the 
progress of the complaint, it may be washed with the 
common soft soap and water; or with a lather made by 
mixing equal portions of soft soap and unguentum sal- 
phuris in warm water. More stimulant ointments will 
then be requisite., such as the unguentum hydrargyri 
nitrati, ung. hydrargyri nitrico-oxydi, the tar, and sul- 
phur ointments, or the ung. acidi nitrosi of the Edin- 
burgh pharmacopoeia. These, and other stimulant ap- 
plications,* succeed in different individuals, in the inert 
state of the P. furfurans; but they must be intermitted, 
in case the inflammation and discharge return. 

3. The Porrigo lupinosa is characterized by the 
formation of dry, circular scabs, of a yellowish-white 
colour, set deeply in the skin, with elevated edges and 

* A long catalogue of stimulants, of similar quality, may be 
collected from the writings of the Greeks, as remedies for the 
furfuraceous Porrigo : such as liniments of frankincense and 
vinegar, or the same gum with wine and oil ; others prepared 
with oil of rue, litharge, and vinegar; or with stavesacre and oil.; 
lotions of the decoction of fenugreek, the roots of beet, and of 
the cucumis silvestris, Sec. See Oribas. Synops. lib. viii. cap. 
25. — Aetius, tetrab. ii. serm. ii. cap. 76. — Alex. Trail, lib. jL 
cap. 4. 

Y 



170 PUSTULE: 

a central indentation or depression, sometimes contain- 
ing a white scaly powder, and resembling, on the whole, 
the seeds of lupines * These scabs are formed upon 
small separate clusters of achores, by the concretion of , 
the fluid, which exudes when they break; and they ac- 
quire, when seated on the scalp, the size of a sixpence. 
Frequently there is also a thin white incrustation, co- 
vering the intervening parts of the scalp, which com- 
monly exfoliates; but if allowed to accumulate through 
inattention to cleanliness, it forms an elevated crustace- 
ous cap. The disease, however, is not exclusively con- 
fined to the head; but sometimes appears on the extre- 
mities, where the little white and indented scabs do not 
exceed two lines in diameter. This variety of Porrigo 
is liable to increase much, if neglected; and is usually 
tedious and of long duration. 

The first object in the management of the P. lupino- 
sa, is to remove the crusts and little indented scabs, by a 
diligent application of soap and water, or other emolli- 
ent applications. If the scalp be the seat of the disease, 
the previous removal of the hair will be necessary. If 

* From this resemblance, the same epithet was applied to the 
disease by Haly Abbas, who has distinguished six species. " Quin- 
ta est lu/iinosa, sicca, et, colore alba, lupino similis, a qua quasi 
cortices et squamae fluunt albae." (Theorice, lib. viii. cap. 18.) 
See also Guid. Cauliac. tract, vi. cap. !. — Sennert. lib. v. p. i. cap. 
32. It is the tinea lufxina of Astruc and Sauvages ; and the Por- 
rigo lu/iina, and scabies capitis lufxina, of Plenck, (loc. cit.) The 
" teigne/«-uewse" of Alibert appears to be the Porrigo lupinosa. 
Opiate 1.) 



fORRIGO. 171 

the scabs are not penetrable by these ablutions or by 
ointments, or if any thick intervening incrustation is 
present, a lotion of the liquor potassae,* or of the muri- 
atic acid, in a diluted state, may be employed. When 
the surface is cleared, the ointment of cocculus Indicus 
may be applied to the red and shining cuticle; and af- 
terwards the more stimulant unguents, as in the case of 
P. furfurans, with regular daily ablution, will complete 
the cure. 

4. The Porrigo scutulata, (Plate XXXIX.) popu- 
larly termed the ringworm of the scalp, appears in dis- 
tinct and even distant patches, of an irregular circular 
figure, upon the scalp, forehead and neck.f It com- 
mences with clusters of small light-yellow pustules, 
which soon break and form thin scabs over each patch, 
which, if neglected, become thick and hard by accumu- 
lation. If the scabs are removed, however, the surface 
of the patches is left red, and shining, but studded with 
slight elevated points, or papulae, in some of which mi- 
nute globules of pus again appear, in a few days. By 
these repetitions of the eruption of achores, the incrus^ 

* An alkaline lotion m£y be made with the proportions of a 
drachm of the aqua kali puri, two or three drachms of oil, and an 
ounce of water — « Imprimis salia lixivia" says Prof. Selle, " ad 
crustam tarn firmam atque alias insolubilem emolliendam sunt 
apta." Medic. Clin. 187. 

t The " teigne gra?iulee" of Alibert (plate 2) appears to be a va- 
riety of P. scutulata. 



m PUSTULE: 

tations become thicker, and the areas of the patches ex- 
tend, often becoming confluent, if the progress of the 
disease be unimpeded, so as to affect the whole head 
As the patches extend, the hair covering them becomes- 
lighter in its colour, and sometimes breaks off short; and 
as the process of pustulation and scabbing is repeated, 
the roots of the hair arc destroyed, and at length there 
remains uninjured only a narrow border of hair round 
the head. 

This very unmanageable form of Porrigo generally 
occurs in children of three or four years old and up- 
wards, and often continues for several years. Whether 
the circles remain red, smooth, and shining/ or become 
dry and scurfy, the prospect of a cure is still distant: for 
the pustules will return, and the ulceration and scabbing 
will be repeated. It can only be considered as about 
to terminate, when the redness and exfoliations disap- 
pear together, and the hair begins to grow of its natural 
colour and texture. 

The disease seems to originate spontaneously in chil- 
dren of feeble and flabby habit, or in a state approaching 
to marasmus, who are ill-fed, uncleanly, and not suffi- 
ciently exercised: but it is principally propagated by 
contagion; i. e. by the actual conveyance of the matter 
from the diseased to the healthy, by the frequeut con- 
tact of the heads of children, but more generally by the 
use of the same towels, combs, caps, and hats. Whence 
the multiplication of boarding-schools appears to have 
given rise to an increased prevalence of this disease, 



PORRIGO. 173 

among the more cleanly classes of the community, at 
the present time. For such is the anxiety of parents to 
regain the lost years of education, that they too often send 
their children to these schools, when capable of commu- 
nicating the infection, although supposed to be cured; 
against which no vigilance on the part of the superin- 
tendants can afford a sufficient security. 

The principles of local treatment already laid down, 
are particularly applicable in this species of Porrigo. 
While the patches are in an inflamed and irritable con- 
dition, it is necessary to limit the local applications to 
regular ablution, or sponging, with warm water, or some 
emollient fomentation.* Even the operation of shaving, 
which is necessary to be repeated at intervals of eight or 

* This mode of treatment was recommended by some of the 
ancients. Oribasius observes, that " if there is much heat or in- 
flammation connected with the achores,this must be first alleviated 
by a moist sedative." (Synops. lib. viii. cap. 27.) Aetius also ob- 
serves, " Quod si incideris in achores inflammatos et dolentes, 
dolorem prius liquido medicamento concoctorio mollienteque ac 
leni mitigabis, &c." (tetrab. ii. serm. ii. cap. 68.) And among 
the moderns, Heister has made a similar discrimination respecting 
the treatment of Porrigo. He recommends, in all instanees, in 
the commencement of the disease, the use of mild, emollient ap- 
plications ; as cream with cerussa, oleum ovorum, " ung. de enula 
de cerussa, diapompholygos, aliudve simile saturninum," while 
moderate alteratives of calomel, antimony, Sec. are given inter- 
nally. He affirms that the application of mercurial and sulphur 
ointments, in the first instance, is exceedingly pernicious. Chirurg. 
part. i. lib. v. cap. 10. 



174 PUSTULE: 

ten days, produces a temporary increase of irritation. 
At this time the patient should wear a light linen cap, 
which should be frequently changed; and all stimulant 
lotions and ointments, which tend only to aggravate the 
disease, should he proscribed. 

In the progress of the disorder, various changes take 
place, which require corresponding variations of the 
method of treatment. By degrees the inflammatory state 
is diminished, and a dry exfoliation and scabbing ensue: 
but again the pustular eruption breaks out, and the 
patches become again red and tender; or, in some cases, 
without much redness, there is an acrimonious exudation, 
with considerable irritability of the scalp. In other in- 
stances, the surface becomes inert, and in some degree 
torpid, while a dry scaly scab constantly appears, and 
active stimulants are requisite to effect any change in the 
disorder. It is very obvious, as Dr. Willan used to re- 
mark, that the adoption of any one mode of practice, or 
of any single pretended specific, under these varying cir- 
cumstances of the disease, must be unavailing, and often 
extremely injurious. 

In the more irritative states, the milder ointments, 
such as those prepared with cocculus Indicus, with the 
submuriate of mercury, the oxide of zinc, the superace- 
tate of lead, or with opium or tobacco, should be em- 
ployed; or sedative lotions, such as decoctions or infu- 
sion of poppy heads, or of tobacco, may be substituted. 
Where there is an acrimonious discharge, the zinc and 
saturnine ointments, with the milder mercurial ones, such 



PORRIGO. 175 

as the ung. hydrargyri praecipitati, or the ointment of 
calomel, or a lotion of lime-water with calomel, are ad- 
vantageous. 

According to the different degrees of inertness, which 
ensue, various well-known stimulants must be resorted 
to, and may be diluted, or strengthened, and combined, 
according to the circumstances. The mercurial oint- 
ments, as the ung. hydrargyri praecipitati, hyd. nitrico- 
oxydi, and especially of the hydrargyrus nitratus, are 
often effectual remedies: and those prepared with sul- 
phur, tar, hellebore, and turpentine, the unguentum 
elemi, &c. separately or in combination, occasionally 
succeed; as well as preparations of mustard,* stavesacre, 
black pepper,f capsicum, galls, rue, and other acrid 
vegetable substances. J Lotions containing the sulphates 
of zinc and copper, or the oxymuriate of mercury, in 
solution, are likewise occasionally beneficial. 

* See Sennert. loc. cit. — Underwood on the Dis. of Children 
vol. ii. 

t There is an unguentum piperis nigri in the Dublin pharmaco- 
poeia, of the efficacy of which Dr. Tuomy speaks highly. See his 
Essay on the Diseases of Dublin. 

} The ancients were accustomed to employ a similar collection 
of stimulants for the achores ; among which were sulphur vivum, 
atramentum sutorium (sulphate of iron,) tar, burnt paper with 
oil, soap ; oil of rue and of myrtle ; resin, myrrh, and frankincense, 
with wine and vinegar, Sec. Vinegar was deemed an efficacious 
remedy. " Acetum vero acerrimum ad achoras omni tempore 
accommodatum est." See Oribas. Synops. lib. viii. 27. Aet. tet 
ii. serm. ii. cap. 68. 



170 PUSTULtE: 

In the very dry and inert state of the patches, the more 
caustic substances are often extremely successful. Thus 
I have seen a lotion, containing from three to six grains 
of the nitrate of silver in an ounce of distilled water, ef- 
fectually remove the disease in this condition. Touch- 
ing the patches with the muriated tincture of iron, or 
with any of the mineral acids, slightly diluted, in some 
cases removes the morbid cuticle, and the new one as- 
sumes a healthy action * The application of a blister, 
in like manner, sometimes effectually accomplishes the 
same end. But, in many instances, the effect of these 
renovations of the cuticle is merely temporary, and the 
disease returns in a week or two, upon the new surface. 

Professor Hamilton, of Edinburgh, who considers the 
ring-worm of the scalp, as "quite different from the scalled 
head," affirms, in a late publication, that he has seldom 
failed to cure the former, by the use of the unguentum ad 
scabiem of Banyer. For delicate children, he dilutes 
this ointment with an equal portion of simple cerate, and 
sometimes alternates the use of it with that of common 
basilicon.f 

* Mr. P. Fernandez mentioned to me an instance of speedy 
recovery, which followed a single application of the strong sul- 
phuric acid, which was instantaneously washed off. A new and 
healthy cuticle succeeded. 

f See his " Hints on the Management of Children." — The 
acrid ointment of Banyer consists of ceruss. jfoss, litharg. aur. fij. 
alum. ust. 3'iss, mercur. suhlim. ijiss, sevi porcin. Ib'ij, terebinth. 
Ven. tbss. See his Pharmacopoeia Pauperum. I have used this 



PORRIGO. 177 

These various applications are enumerated, because 
not one of them is always successful, singly, even un- 
der circumstances apparently the sajne. They must be 
varied and combined; and the best criterion in the 
choice and combination of them is, the degree of exist- 
ing irritation in the morbid parts, or in the general habit. 
The rude and severe employment of depilatories, which 
some practitioners have recommended, is to be depreca- 
ted, as often inflicting great injury to the scalp, and re- 
tarding, rather than expediting, the progress to recovery. 

I have said nothing respecting the administration of 
internal medicine in the Porrigo scutulata; because it 
is often merely local, being communicated by contagion 
to children in other respects healthy. But in those in 
whom it appears in combination with cachectic symp- 
toms, chalybeate medicines, or the decoction of cin- 
chona and alteratives, must be prescribed, according to 
the particular indications; and the diet, clothing, and 
exercise of the patient, must be carefully regulated. 

5. Porrigo decalvans. (Plate XL.) This singular 
variety of the disease presents no appearance whatever, 
except patches of simple baldness, of a more or less 
circular form, on which not a single hair remains, while 

ointment, somewhat diluted, in a few cases of this disease, since 
the first edition of this Synopsis was published; and I have found 
it, like other applications, sometimes successful, but frequently 
inert and useless. 



1*8 PUSTULE: 

that which surrounds the patches is as thick as usual 
The surface of the scalp, within these areas, is smooth- 
shining, and remarkably white.* It is probable, though 
not ascertained, that there may be an eruption of mi- 
nute achores about the roots of the hair, in the first 
instance, which are not permanent, and do not discharge 
any fluid. The disease, however, has been seen to 
occur, in one or two instances, in a large assemblage of 
children, among whom the other forms of the Porrigo 
prevailed. But in other cases, and also in adults, it 
has appeared where no communication could be traced 
or conjectured. The areae gradually enlarge, and 
sometimes become confluent, producing extensive bald- 
ness, in which condition the scalp remains many weeks, 
especially if no curative measures are adopted. The 
hair, which begins to grow, is of a softer texture, and 
lighter colour, than the rest; and, in persons beyond 
the middle age, it is gray. 

If the scalp is cleared by constant shaving, and at 
the same time some stimulant liniment be steadily ap- 
plied to it, this obstinate affection may be at length 
overcome, and the hair will regain its usual strength 
and colour. In fact, until this change takes place, the 

* Celsus, and after him some other writers, have described this 
affection under the appellation of " Area." Under this generic 
term, he comprises two varieties, called by the Greeks jilofiecia, 
and Ofi/iiasis : the former of which spreads in irregular patches ; 
and the latier in a serpentine form, round both sides of the head, 
from the occiput. De Medicina, lib. vi. cap. 4. 



P0RRIG0. . 179 

means of cure must not be intermitted.* Some of the 
more active ointments, mentioned under the preceding 
head, may be employed with friction; but liniments 
containing an essential oil dissolved in spirit, (for in- 
stance, two drachms of the oil of mace, in three or four 
ounces of alcohol,) or prepared with oil of tar, petro- 
leum Barbadense, camphor, turpentine, &c. are more 
efficacious. 

6. Porrigo favosa. (Plate XLI.) This species of 
the disorder consists of an eruption of the large, soft, 
straw-coloured pustules, denominated/era (Def. 5. d.).f 
These are not in general globular, with a regularly cir- 
cular margin; but somewhat flattened, with an irregular 
edge, and surrounded by a slight inflammation. They 
occur on all parts of the body; sometimes on the scalp 
alone, and sometimes on the face, or on the trunk and 

* All that can be prescribed, respecting the treatment of this 
affection, has been expressed by Celsus with his usual terseness. 
" Quidam hasc genera arearum scalpello exaspcrant : quidam illi- 
nunt adurentia ex oleo, maximeque chartam combustam : quidam 
resinam terebinthinam cum thapsia inducunt. Sed nihil melius 
est, quam novacula quotidie radere : quia, cum paulatim summa 
pellicula excisa est, adaperiuntur pilorum radiculse. Neque ante 
oportet desistere, quam frequentum pilum nasci apparuerit. Id 
autem, quod subinde raditur, illini atramento sutorio satis est." 
Loc. cit. 

f This has been called tinea favosa by Haly Abbas, Astruc, 
and Sauvages, — and scabies capitis /avosa by Plenck. 



180 PUSTULE: 

extremities only; but most commonly they spread from 
the scalp, especially from behind the ears, to the face, 
or from the lips and chin to the scalp, and occasionally 
from the extremities to the trunk and head.* They 
are usually accompanied with considerable itching. 
Children from six months to four years of age are 
most liable to this eruption; but adults are not unfre- 
quently affected with it. 

The pustules, especially on the scalp, appear at first 
distinct, though near together; but on the face and 
extremities they generally rise in irregular clusters, 
becoming confluent when broken, and discharging a 
viscid matter, which gradually concretes into greenish, 
or yellowish, semi-transparent, scabs. The disease 
extends by the successive formation of new blotches, 
which sometimes cover the chin, or surround the mouth, 
and spread to the cheeks and nose; and, on the scalp, 
the ulceration ultimately extends, in a similar manner, 
over the whole head, with a constant discharge, by 
which the hair and moist scabs are matted together. 
Under the last-mentioned circumstances, pediculi are 
often generated in great numbers, and aggravate the 
itching and irritation of the disease. On the face, too, 
a similar aggravation of the symptoms is occasioned, in 
children, by an incessant picking and scratching about 

* Sauvagcs and several other writers have given a new title to 
the eruption, when it thus spreads from one part to another ; such 
as tinea volatka, ignis volaticus> &c. 



PORRIGO. 181 

the edges of the scabs, which the itching demands, 
and by which the skin is kept sore, and the ulceration 
extended; while the scabs are thickened into irregular 
masses, not unlike honey comb, by the accumulating 
and concreting discharge. On the lower extremities 
considerable ulcerations sometimes form, especially 
about the heels and roots of the toes; and the ends of 
the toes are sometimes ulcerated, the pustules arising 
at their sides, and even under the nails. 

The ulcerating blotches seldom continue long, or ex- 
tend far, before the lymphatic system exhibits marks of 
irritation, probably from the acrimony of the absorbed 
matter. When the scalp or face is the seat of the dis- 
ease, the glands on the sides of the neck enlarge and har- 
den, being at first perceived like a chain of little tumours, 
lying loose under the skin; and the submaxillary and 
parotid glands are often affected in a similar manner, 
At length some of them inflame, the skin becomes dis- 
coloured, and they suppurate slowly, and with much 
pain and irritation. The eruption, in these situations, 
is likewise often accompanied by a discharge from be- 
hind the ears, or from the ears themselves, with a tumid 
upper lip, and inflammation of the eyes, or obstinate ul- 
cerations of the edges of the eyelids. When the erup- 
tion appears on the trunk, although the pustules there are 
smaller and less confluent, and the scabs thinner and 
less permanent, the axillary glands are liable to be 
affected in the same way. 

The discharge from the ulcerated surfaces, especially 



182 PUSTULE: 

on the scalp, when the crusts and coverings are removed, 
exhales an offensive rancid vapour, not only affecting 
the organs of smell and taste, but the eyes, of those who 
examine the diseased parts.* The acrimony of the dis- 
charge is also manifested by the appearance of inflam- 
mation, followed by pustules, ulceration, and scabbing, 
on any portion of the sound skin, which comes into fre- 
quent contact with the parts diseased: thus, in young 
children, the breast is inoculated by the chin, and the 
hands and arms by contact with the face. The arm and 
breast of the nurse are also liable to receive the erup- 
tion in the same manner; but it is not so readily com- 
municated to adults as to children. 

The duration of this form of Porrigo is very uncer- 
tain; but it is, on the whole, much more manageable 
than the P. scutulata and decalvans. Young infants of- 
ten suffer severely from the pain and irritation of the 
eruption, and of the glandular affections which it in- 
duces; and those who are bred in large towns, and are 
ill fed and nursed, are thus sometimes reduced to a 
state of fatal marasmus. 

The Porrigo favosa requires the exhibition of the 
same alteratives internally, which have been recom- 
mended for the cure of the P. larvalis, in doses propor- 
tioned to the age and strength of the patients. The diet 
and exercise should also be regulated with care: all crude 

* It has been supposed that the similarity of the odour of this 
discharge to that of garlic (fiomnn) gave rise to the appellation of 

Porrigo. 



PORRIGO. 188 

vegetables and fruits on the one hand, and stimulating 
substances, whether solid or fluid, on the other, should 
be avoided; and milk, puddings, and a little plain ani- 
mal food or broths, should be alone recommended. If 
the patient be of a squalid habit, or the glandular affec- 
tions severe, the bark and chalybeates, or the solution 
of muriate of barytes united with the former, will con- 
tribute materially to the restoration of health. 

There is commonly some degree of inflammation pre- 
sent, which contraindicates the use of active stimulants 
externally. The unguentum zinci, or the ung. hydrar- 
gyri praecipitati, mixed with the former, or with a satur- 
nine ointment, will be preferred as external applications, 
especially w r here the discharge is copious: and the oint- 
ment of the nitrate of mercury, diluted with about equal 
parts of simple cerate and of the ceratum plumbi su- 
peracetatis, is generally beneficial; but the proportion of 
the unguentum cerae must be varied according to the de- 
gree of inflammation. All stiff and rigid coverings, 
whether of oiled silk, or, according to a popular prac- 
tice, of the leaves of cabbage, beet, &c. should be pro- 
hibited; for they often excite a most severe irritation. I 
have witnessed, in several instances, an universal ulcera- 
tion, with copious purulent discharge, and a highly in- 
flammatory and painful state of the scalp, exciting even 
a considerable degree of symptomatic fever, produced 
by such applications. The substitution of a poultice, in 
these cases, removed this irritative condition in two or 



184 PUSTULE: 

three days, and the disease was speedily subdued by the 
treatment above recommended. 

It may be mentioned, in conclusion, that an eruption 
of/aw is sometimes seen on the face, (Plate XLII.) ears, 
neck, and occiput, in adults;* in whom it is preceded 
and accompanied by considerable derangement of the 
constitution, headache, pain of the stomach, loss of ap- 
petite, constipation, and some degree of fever. The pus- 
tules become confluent, discharge a viscid humour, and 
scab, as in the eruption just described; but they are sur- 
rounded by more extensive inflammation, and become 
harder and more prominent, somewhat resembling, in 
this respect, the ecthyma. Their course, however, is 
more rapid than that of the ecthyma, or of the tubercular 
sycosis, to which also the disease also bears some affinity. 
A cathartic, followed by the pilula hydrargyri submuria- 
tis of the last pharmacopoeia, or Dr. Plummer's pill, and 
a vegetable tonic, will be found serviceable; and the mild 
external applications, above mentioned, must be em- 
ployed, according to the degree of inflammation present. 

A sudden eruption of Porrigo favosa, accompanied 
by fever, occasionally takes place also in children. A 
considerable alarm was excited by such an occurrence, 
in a family which I was requested to see, in which the 
disease was deemed to be some new or anomalous conta- 
gion. The first patient, aged five, was seized with se- 

* Of this form of Porrigo favosa on the cheeks, the 16th plate- 
of M. Alibert appears to be a representation. He calls it " Dar- 
tre crustaceeflavescente.'* 



ECTHYMA. 185 

vere fever, in which the pulse was at one time 140, and 
continued at 110 for several days: at the same time, 
clusters of favous pustules appeared behind the ears t 
which were speedily followed by others on the scalp, 
and about the apertures of the nostrils, which they plug- 
ged up as the scabs were formed. A few days after the 
commencement of this attack, a younger child, aged two 
years, was seized in a similar manner; but in her, the 
pustules appeared also about the chest, the glands of the 
neck swelled, and the abdomen became tumid. The 
contagion was immediately, though but locally, received 
by the mother and the nurse; the former of whom was 
inoculated about the mouth, by kissing the children; the 
latter in the palm of the hand. These children were 
somewhat squalid, and apparently ill nursed, especially 
in respect to cleanliness and exercise. 



III. ECTHYMA. 
The Ecthyma* is an eruption of the inflamed pus- 
tules, termed Phlyzacia (Def. 5. a.). They are usually 

* The term BxSvpx seems to have been used by the Greeks in a 
general sense, and nearly synonymous with e|«v0jjju*, or eruption. 
Perhaps the more elevated and inflammatory eruptions were par- 
ticularly called ecthymata ; since, as Galen has observed, in his 
Commentary on the third book of the Epidemics of Hippocrates, 
the term is derived from exOvav, " quod est efofjtcav {imfietu erum- 
ji ere) in iis quae sponte extuberant in cute." (§51.) See also 
Erotian de voc. apud Hippoc. ; — and Foes, CEconom. Hipp, ad 

a a 



186 PUSTULE: 

distinct, arising at a distance from each other, seldom 
very numerous, unaccompanied by fever, and not conta- 
gious. 

This eruption does not very frequently alone demand 
the assistance of medicine. It is commonly indicative 
of some state of distress, if that expression may be used,, 
under which the constitution labours ; and, although it 
is not attended by actual fever, yet a degree of general 
irritation, or erethism, is often present with it. It shows 
itself under three or four varieties, and is usually attri- 
buted to long continued exertion and fatigue, to much 
watching, to imperfect nutriment, to the influence of 
cold, to a state of pregnancy, or to the debilitating effects 
of previous malignant fevers, especially of smallpox, 
measles, and scarlatina. It occurs most frequently on 
the extremities, but sometimes over the whole body, 
face, and scalp. The diagnosis of this eruption from 
the contagious pustular diseases, as well as from some 
of the secondary appearances of syphilis, is of consider- 

voc. erJvpccTx. This view of the subject has led many authors, 
Fernel, Pare, Vidus Vidius, Sennert, Sebizius, &c. to believe, that 
the terms ecthymata and exanthemata were used specifically, as 
the denominations of smallpox and measles. " Variolas vocant 
tx.9vfi.x7-x, pustulas extumescentes, morbillos autem «f*v0jjf«,«T* no- 
minant, maculasin cute apparentes, 8cc." See a learned Treatise 
of Melchior Sebizius, De Variol. et Morbil. Argent. 1642. These 
views sanction the appropriation of the term to the " pustulae ex- 
tumescentes" of this genus. 



ECTHYMA. 187 

able importance in practice, which renders it necessary 
to notice this genus. 

1. The Ecthyma vulgare (Plate XLIII. Fig. 1.) is 
the slightest form of the disorder, and consists of a par- 
tial eruption of small hard pustules, on some part of the 
extremities, or on the neck and shoulders, which is com- 
pleted in three or four days. In the course of a simi- 
lar period, the pustules successively enlarge, and inflame 
highly at the base, while pus is formed in the apex; and 
in a day or two more they break, pour out their pus, and 
afterwards a thinner fluid, which speedily concretes into 
brown scabs. In a week more, the soreness and inflam- 
mation subside, and the scabs soon afterwards fall off, 
leaving no mark behind. 

This eruption commonly supervenes on a state of 
languor, of some continuance, with loss of appetite, 
irregularity of the alvine evacuations, and pains in the 
stomach or limbs. Young persons are principally sub- 
ject to it, and children are sometimes affected with it, 
especially in the spring or summer, after being over- 
heated, or fatigued, or disturbing the digestive organs 
by improper food. The constitutional derangement is 
not immediately relieved on the appearance of the erup- 
tion, but ceases before its decline. The use of gentle 
purgatives in the early stage, and of the decoction of 
cinchona, after the maturation of the pustules, appears 
to comprehend all that is requisite in regard to medi- 
cine. 



188 PUSTULE. 

2. The Ecthyma infantile occurs in weakly infants 
during the period of lactation, when an insufficient nu- 
triment is afforded them. The pustules are, in appear- 
ance, the same as those of the preceding species, and go 
through similar stages of progress, in the same time 
But the disorder does not terminate here: fresh erup- 
tions of phlyzacia continue to rise in succession, and to 
a much greater extent than in the E. vulgare, appearing 
not only over the extremities and trunk, but on the 
scalp, and even on the face; m which situation the pus- 
tules do not occur except in the fourth species of Ec- 
thyma. Hence also the duration of the eruption is much 
greater than in the preceding species, being sometime* 
protracted for several months. Yet the patients usual- 
ly remain free from fever, and the pain and irritation 
seem to be inconsiderable, except when a few of the 
pustules become very large and hard, with a livid base, 
and ulcerate to some depth: in this case, also, a slight 
whitish depression is permanently left on the seat of the 
pustule. 

The principal means of cure will be found in chang- 
ing the nurse: and the advantages of better aliment will 
be aided by proper clothing and exercise, as well as by 
moderate alteratives, and by the cinchona, or chaly- 
beates. 

3. Ecthyma luridum, (Plate XLIII. Fig. 2.) The 
most obvious peculiarity of this variety of the phlyza- 
cious pustules is the dark red colour of their base, which 



ECTHYMA. 189 

is likewise hard and elevated. But they differ also from 
the two preceding varieties, in being of a larger size; and 
from the first, in the slow but long succession in which 
they arise, and in the extent of surface over which they 
spread, the face alone being exempt from their occur- 
rence. This form of the disease is most frequently seen 1 
in persons of an advanced age, who have injured their 
constitutions by hard labour, intemperance in the use of 
spirits, and night-watching; and it is most severe in the 
winter season. 

Under these circumstances, the pustules, as might be 
expected, are slow in healing. They break in the course 
of eight or ten days, and discharge a curdly, sanious, or 
bloody matter: the ulcerated cavities, extending beyond 
the original boundary, soon become filled with hard, 
dark scabs, and remain surrounded by a deep-seated 
hardness in the flesh, and dark inflamed borders, until 
the scabs are about to separate, — a period generally of 
several weeks, and sometimes of many months. The 
scabs are commonly firmly seated; but if removed by 
violence, they are not speedily reproduced; on the con- 
trary, tedious ulcers, with callous edges and a sanious 
discharge, are often thus occasioned. 

The treatment of this Ecthyma must be chiefly direct- 
ed to the amendment of the constitution, by means of 
good diet, by the occasional use of the warm bath, and 
by the bark, and vegetable decoctions, internally. 

Asymptomatic Ecthyma, which bears a considerable 
analogy to the E. luridum, sometimes comes on during 



190 PUSTULE: 

the cachectic state which follows the measles, and occa- 
sionally after the scarlet fever and smallpox. It is ac- 
companied with a hectic fever, laborious respiration, and 
swellings of the glands; and is attended with extreme 
pain and soreness, sometimes with a tedious sloughing, 
in some of the larger pustules, which, in children par- 
ticularly, are productive of considerable distress. The 
phlyzacia arise in various parts of the extremities and 
trunk, and are highly inflamed at their bases, even after 
the scabbing takes place. The whole duration of the 
disease is often from one to two months; and the ma- 
jority of patients struggle through it. 

Opiates and the warm bath afford essential relief to 
the distressing irritation occasioned by this affection; and 
a liberal use of the bark, where it can be so adminis- 
tered, both shortens and alleviates the disease. 

4. Ecthyma cachecticum. (Plate XLIV.) An exten- 
sive eruption of phlyzacious pustules not unfrequently 
occurs, in connexion with a state of cachexia, apparently 
indicative of the operation of a morbid poison in the 
habit: for the phenomena of the disease much resemble 
some of the secondary symptoms of syphilis, and it is 
often treated as syphilitic. 

The disorder usually commences with a febrile par- 
oxysm, which is sometimes considerable. In the course 
of two or three days, numerous scattered pustules ap- 
pear, with a hard inflamed base, sometimes first on the 
breast, but most commonly on the extremities: and these 



ECTHYMA. 191 

are multiplied day after day by a succession of similar 
pustules, which continue to rise and decline for the 
space of several weeks, until the skin is thickly studded 
with the eruption, under various phases. For, as the 
successive pustules go through their stages of inflamma- 
tion, suppuration, scabbing, and desquamation, at similar 
periods after their rise, they are necessarily seen under 
all these conditions at the same time; the rising pustules 
exhibiting a bright red hue at the base, which changes 
to a purple or chocolate tinge, as the inflammation de- 
clines, and the little laminated scabs are formed upon 
their tops: when these fall off, a dark stain is left upon 
the site of the pustules. In different cases the eruption 
varies in its distribution; it is sometimes confined to the 
extremities, where it is either generally diffused, or clus- 
tered in irregular patches; but it frequently extends also 
over the trunk, face, and scalp. The pustules which 
occupy the breast and abdomen are generally less pro- 
minent than those on the face and arms, contain less 
matter, and terminate rather in scales than in scabs. 

The febrile symptoms are diminished, but not remov- 
ed, on the appearance of the eruption; for a constant 
erethism or hectic continues during the progress of the 
disease. It is accompanied by great languor, and by 
much depression both of the spirits and muscular strength; 
by headache and pains of the limbs, which are de- 
scribed as rheumatic; and by restlessness and impaired 
digestion, with irregularity of the bowels. There is 
commonly also some degree of ophthalmia, affecting both 



m PUSTULiE: 

tlie conjunctiva and the tarsi; and the fauces are the, 
seat of a slow inflammation, which is commonly accom- 
panied by superficial ulcerations. 

The duration of this disease seems to be from two to 
four months, in the course of which time, by the aid of 
the vegetable tonics, cinchona, sarsaparilla, serpentaria, 
&c. with antimonials, and the warm bath, the constitu- 
tion gradually throws off the morbid condition which 
gives rise to it. The administration of mercury is not 
necessary to its cure, nor does it appear to accelerate 
recovery. 

The diagnosis between this disease and the syphilitic 
Ecthyma, is to be collected rather from the history of 
the disease, than from the prominent symptoms; unless, 
indeed, we are ready to concede to a recent writer, that 
this and similar affections are never the result of the 
true syphilitic poison.* 

* See Part First of an " Essay on the Venereal Diseases, whicit 
have been confounded with Syphilis," by Richard Carmichael, 
President of the Royal College of Surgeons, Dublin. 1814. If I 
rightly comprehend this interesting but unfinished work, Mr. 
Carmichael maintains, that the true syphilitic ulcer is followed ex- 
clusively by one erufition, the scaly copper blotch, or lepra venerea, 
described by Dr. Willan. It will row scarcely be doubted, in- 
deed, that the above-mentioned Ecthyma, and some other eruptive 
diseases of an analogous character, are frequently, though erro- 
neously, pronounced syphilitic ; but we are not prepared, by the 
present state of the evidence, to limit the syphilitic eruptions thu c 
narrowly, 



VARIOLA. 193 

Dr. Willan mentioned a topical variety of Ecthyma, 
occurring on the hands and fingers of workmen em- 
ployed among metallic powders, which I have never 
seen. As it commences in a vesicular form, and though 
afterwards purulent, produces irregular patches of thin 
scabs, it should perhaps have been referred to eczema. 



IV. VARIOLA. 
SMALLPOX. 

In the completion of this arrangement, the smallpox 
should be the subject of investigation in this place; but 
I am induced, by several considerations, to omit the in- 
quiry at present. While, on the one hand, the disease is 
universally known, and has been amply described by 
medical writers, from Rhazes downwards; it affords, on 
the other, a topic too copious to be satisfactorily disposed 
of in a single chapter. It might, indeed, have been 
hoped that the general diffusion of vaccination would, 
ere now, have rendered a critical knowledge of the va- 
rieties of this pestilential malady less necessary to prac- 
titioners: and I still confidently anticipate the arrival of 
the period, when the just estimation of the value of Dr. 
Jenner's discovery, by all ranks of people, will supersede 
the necessity of making smallpox an object of our study. 
At all events, the diagnosis of the disease, where it is 
sufficiently severe to demand the assistance of medicine,, 
is seldom obscure, and one of the principal objects ©f 
Bb 



194 PUSTULE: 

this treatise is the discrimination of cutaneous symptoms, 
I am, besides, anxious to limit both the bulk and the 
price of this volume within moderate bounds. I shall, 
therefore, proceed to the remaining disease of the pus- 
tular order, which, common and vulgar as it is, occa- 
sionally baffles the best attempts both to distinguish and 
to cure it. 



V. SCABIES.* 
ITCH. 

This troublesome disease, which, from its affinity 
with three orders of eruptive appearances, pustules, ve- 

* The Greek term Psora has been very generally, but incor- 
rectly, adopted for the designation of this disease, in consequence 
of the example of some of the early translators, who considered 
Scabies (quasi scabrities) as synonymous with -^ap*, which, we 
have already seen, (page 6, note) was universally employed by 
the Greeks as denoting a scaly or scurfy disorder of the skin 
more rough than lichen, but less scaly than lepra. They did 
indeed occasionally use the term, in conjunction with the epithet 
iXrtwhlt, or ulcerating, as applicable to a pustular disease, apparent- 
ly the impetigo; but when used alone, it invariably implied the 
dry scaly or scurfy tetter, psoriasis. (See above, ord. ii. gen. 2.) 
Sir John Pringie, indeed, after noticing this inaccuracy, concludes 
that the itch was probably unknown, or at least uncommon, in an- 
cient times. " The psora of the Greeks has generally been sup- 
posed to be the itch; but as this does not appear by the descrip- 
tion they give of it, I should conclude, Sec." (On Diseases of the 
Army, part iii. chap. 5.) 



SCABIES. 195 

sides, and papula?, almost bids defiance to any attempt 
to reduce it to an artificial classification, is not easily 
characterized in few words. An extreme latitude in 
the acceptation of the term has indeed been assumed 
by writers, from Celsus downwards; and no distinct or 
limited view of the disease has been given, until near 
our own times. Celsus has included other forms of pus- 
tular disease among the different species of Scabies; and 
some of the earlier writers, after the revival of learn- 
ing, considered almost all the eruptions, to which the 
skin is liable, as modifications of this disease: even our 
countryman, Willis, to whom the contagious nature of 
true Scabies, as well as its specific remedy, was well 
known, has not sufficiently separated it from some other 
pustular and pruriginous affections.* 

The Scabies, or Itch, is an eruption of pustules, or 
of small vesicles, which are subsequently intermixed 
with, or terminate in, pustules; it is accompanied by 
constant and importunate itching, but not with fever; 
and is in all its varieties contagious. It appears occa- 
sionally on every part of the body, the face only ex- 
cepted; but most abundantly about the wrists and 
fingers, the fossa of the nates, and the flexures of the 
joints.f 

* See Celsus, lib. v. cap. 28; Plater, de Superfic. Corp. Dolo- 
rib. cap. 17 ; Hafenreffer, Nosodoch. lib. i. cap. 15 ; Willis, Phar- 
mac. Rational, part i. § iii. cap. 6. 

f " Scabies est pustularum fiurulentarum, vel saniosarum, vel 
pafiularum siccarum, ex duriore et rubicundiore cute, eruptio, — 



196 PUSTULjK: 

Among the varieties which the disease assumes, four 
have been distinguished, with considerable accuracy, 
by the vulgar, who, have, indeed, the most ample oppor- 
tunities of becoming acquainted with its character; and 
to these they have given the epithets of rank, watery, 
pocky, and scorbutic itch. Their subdivision was adopt- 
ed by Dr. Willan, with the appropriate titles of Scabies 
papuliformis, lymphatic a, purulenta, and cachectica, 
The characteristics of these varieties, and the diagnosis 
between them and the papular, vesicular, and pustular 
eruptions, which they resemble, I shall endeavour to 
point out; but must admit, at the same time, that the 
practical discrimination, in many of these cases, is more 
difficult than in any other order of cutaneous disease. 

1. The Scabies papuliformis, or rank itch, consists 
of an extensive eruption of minute itching vesicles, which 
are slightly inflamed and acuminated, resembling papu- 
lae when examined by the naked eye. They commonly 
arise first about the bend of the wrist and between the 
fingers, or in the epigastrium; on which parts, as well as 
about the axillae and nates, and in the flexures of the 
upper and lower limbs, they are at all periods most nu- 
merous, and often intermixed with a few phlyzacious 

pruriium, saepc qucque dolorem, creans, — interdum totuin cor- 
pus, facie excep'a invadens, — sxpissin e tamen solos artus exler- 
nos, digitorum imprimis interstilia, occupans." Callisen, Syst. 
Chirurg. Hodiern. i. § 824- 



SCABIES. 197 

pustules, containing a thick yellow matter. The itching 
is extremely troublesome in this form of Scabies, more 
especially when the patient becomes warm after getting 
into bed. The appearance of the disease is modified 
by the abrasion of the tops of the vesicles and pustules, 
and even of the rest of the skin, by the frequent scratch-' 
ing, which cannot be withheld. Hence long red lines 
are here and there left, and the blood and humour con- 
crete upon the vesicles into little brown or blackish 
scabs. 

These mixed appearances, partly belonging to the 
disease, and partly the result of abrasion by the nails, 
being in some measure common to the lichen and 
prurigo, where much scratching is also often employed, 
render the diagnosis of the Scabies papuliferous more 
difficult than it would be from the mere similarity in the 
form of the eruption. But, as the most effectual reme- 
dy for the Scabies is detrimental in the latter affections, 
the distinction is of great practical importance. 

With respect to the eruption itself, the unbroken ele- 
vations in Scabies papuliformis, when carefully examined, 
are found to be vesicular, and not papular; they are 
often intermixed, in particular situations, with pustules; 
and, when they break, are succeeded by scabs: whereas 
in lichen, the papulas terminate spontaneously in scurfy 
exfoliations. In Scabies, the eruption is unconnected 
with any constitutional or internal disorder, and the 
itching is severe: but in lichen, there is commonly som@ 
constitutional affection, and a tingling sensation, as well 



198 PUSTULiE. 

as itching. The highly contagious nature of Scabies 
will, in many cases, have already manifested itself, and 
remove all doubt; for the lichen is not thus communi- 
cable.* 

In prurigo, the papulae, where no friction has been ap- 
plied, retain the usual colour of the skin, are commonly 
flatter, or less acuminated, and present no moisture or 
scab, except when their tops have been forcibly abraded ; 
they are not particularly numerous in the parts above 
mentioned; and they remain long distinctly papular, 
without showing any contagious property. The erup- 
tion which I have called lichen urticatus (see page 13,) 
and which often occurs in weakly children, and exhibits 
a troublesome series of papulae, sometimes intermixed 
with minute vesicles, bears a close resemblance to sca- 
bies, especially when it has been of some continuance. 
But the first appearance of these spots in the shape of 
inflamed wheals, not unlike the inflammation produced 
by the bites of gnats — their subsequent papular or vesi- 
cular appearance, with little or no surrounding inflam- 
mation, — the intermixture of these two states of the 
eruption, — and the ultimate formation of a minute globu- 
lar brown scab, which is set firmly in the apex of each 
elevation, will serve as diagnostic marks. 

2. The Scabies lymphatica, or watery itch, (Plate 
XLV.) is distinguished by an eruption of transparent 

* See the quotation from M. Lorry, supra, p. 8. note. 



SCABIES. 19.9 

vesicles, of a considerable size, and without any inflam- 
mation at their base. They arise in succession, with 
intense itching, chiefly round the wrists, between the 
fingers, on the back of the hands, and on the feet and 
toes: they often occur also about the axillse, the hams, 
the bend of the elbows, and fossa of the nates, where 
they are intermixed with pustules: but they do not fre- 
quently appear, like the papuliform species, over the 
breast and epigastrium, nor on the thighs and upper 
parts of the arms. 

In a day or two the vesicles break; and some of them 
heal, under the little scab that concretes upon them. 
But others inflame, and become pustules, which dis- 
charge at length a yellow matter, and extend into small 
ulcerated blotches, over which a dark scab is ultimately 
formed. — So that, during the progress of the eruption, 
all these appearances are intermixed with each other: 
the vesicles, and pustules, the excoriated blotches dis- 
charging pus, the minute dry scabs, and the larger ones 
succeeding the ulceration, may be observed at the same 
time. This circumstance constitutes one of the points 
of diagnosis between this and other vesicular diseases, 
Of these, however, the herpes and eczema, especially 
the latter, are alone liable to be confounded with Scabies 
lymphatica; for the acute form and short course of all 
the varieties of varicella render that eruption suffi- 
ciently distinct. The herpes, likewise, differs materially 
from Scabies in the regularity of its course and termina- 
tion, and in the arrangement of its vesicles in clusters. 



200 FUSTUUE: 

which are commonly not numerous, and appear on 
those parts which Scabies is not very apt to attack. 

The most difficult diagnosis relates to some of the 
varieties of eczema, which closely resemble this, and 
sometimes the former species of Scabies; so that it is 
not so much from the mere appearances of the eruption, 
as from the consideration of the collateral circumstances, 
that a decision is to be obtained. The eczema can often 
be traced to distinct sources of irritation affecting the 
skin, such as exposure to the solar rays, or to great 
— and to the application of acrid substances, such as 
lime, sugar, mercury, cantharides, &lc It sometimes 
becomes inflamed after the vesicles have discharged 
their lymph, but it does not produce the large phlyza- 
cious pustules; and, although the itching is sometimes 
intense, yet there is commonly a tingling and smarting 
pain with eczema, that does not belong to Scabies; nor 
is it ever, like the latter, communicated by contagion. 

3. The Scabies purulcnta, or pocky itch, (Plate 
XLVI. Fig. 1.) is, I believe, often mistaken by those, 
who confine their notion of the disease to the ordinary 
small and ichorous vesicles of the two former species. 
The eruption consists of distinct, prominent, yellow 
pustules, which have a moderate inflammation round 
their bases, and which maturate and break in two or 
three days, and then ulcerate, with increasing pain and 
inflammation. These pustules commonly appear first, 
and attain- the largest size, on the hands and feet, espe- 



SCABIES. £01 

cially about the knuckles and roots of the toes, between 
the fingers, and particularly between the forefinger and 
thumb, and round the wrists. In these situations, the 
pustules often exceed two lines in diameter, and assume 
a prominent globular form: whence, from their general 
resemblance to the large well maturated pustules of 
smallpox,* (and not from any allusion to syphilis, as some 
have erroneously supposed,) the popular term "pocky" 
has been applied to them. If the disease continue a few 
weeks, the pustules begin to appear on the other parts 
of the body, which Scabies usually attacks, especially 
about the axillae, on the back and shoulders, and on the 
arms and thighs near the joints of the knee and elbow, 
in the fossa of the nates, and sometimes, though of a 
smaller size, even about the epigastrium. In several 
of these situations, where the pustules are largest and 
numerous, they coalesce, and form irregular blotches, 
which ulcerate to some extent, with hardness and eleva- 
tion of the surface; but at length hard and dry scabs are 
formed, which adhere tenaciously for a considerable 
time. 

The majority of the cases of Scabies purulenta, which 
I have seen, have occurred in children, between the age 
of seven years and the period of puberty; and in them it 
not unfrequently assumes this form. 

* "Licet interdum majusculae sint, cum fundamento rubro, et 
pure impleantur, fere tanquam variola." Heberden, Com. de 
Morb. Hist, et Curat, cap. 23. See the Plate, fig. 5. I 

C C 



202 PUSTULE: 

The Scabies purulenta cannot be easily mistaken for 
impetigo, when it occurs in patches, in consequence of 
the large size, the greater prominence, and compara- 
tively small number of its pustules; not to mention the 
absence of the intense itching, and of contagion in the 
former* From the porrigo favosa affecting the extre- 
mities, it will be distinguished chiefly by its situation 
about the fingers, axillae, fossa-natum, and flexures of 
the joints, and by the total absence of the eruption from 
the face, ears, and scalp; by the nature of the dis- 
charge; and by the thin, hard, and more permanent 
scab, which succeeds, instead of the soft, elevated semi- 
transparent scab, formed by the viscous humour of the 
favi. 

The only other disease, with which the Scabies pu- 
rulenta has any affinity, is the ecthyma: but the hard, 
elevated, vivid red or livid base, which surrounds the 
pustules of ecthyma, — their slow progress both towards 
maturity and in the course of suppuration, — the deep 
ulceration, with a hard raised border, and the rounded, 
imbedded scab, which succeed, — as well as the distinct 

* Sauvages has described a variety of Scabies, which he terms 
herfietica (spec. 4.;) Herpes, in his language, as in that of many 
other writers, signifying the same with impetigo in the nomencla- 
ture of Dr. Willan. " Cognoscitur ex signis herpetis et scabici 
simul concurrentibus, in amplos corymbos coeuntibus, papulis 
pruriginosis, rubris, quae squamas albas, farinaceas deponunt." 
But this termination in branny scurf, and the commencement in 
papulae, point out the eruption as a lichen, probably the L, circurn- 
scriptus. 



SCABIES. 203 

and separate distribution of them, — will afford the means 
of discrimination; to which the incessant itching, and 
the contagious property of Scabies, may be added. 

4. Scabies cachectica. This variety of Scabies ex- 
hibits, in different parts of the body, all the appearances 
which belong to the three foregoing species. , It is oc- 
casionally also combined with patches resembling lichen, 
psoriasis, or impetigo, especially in adults, or young per- 
sons approaching the term of puberty; whence it as- 
sumes an ambiguous character. In several instances, 
this form of Scabies has been obviously contagious in 
its double character; and after the scabious affection 
has disappeared, the impetiginous patches have remained, 
for some time, in a drier form, and yielded very slowly 
to medicine. For, although this form of Scabies does 
not so readily spread by contagion, it is much more ob- 
stinate under the use of remedies, than the preceding. 

Another peculiarity of the S. cachectica, is, that it 
often originates, independently of contagion, in weakly 
children, and also in adults, when the constitution is 
suffering under some chronic malady, or debilitated by 
some previous acute disease:* and, however it is pro- 
duced, it is liable to return at intervals, especially in the 

* Sir John Pringle observed, that, in military hospitals, the pa- 
tients often became the subjects of itch after the crisis of fevers. 
Loc. cit. p. Hi. cap. 8. 



204 PUSTULE: 

spring and autumnal seasons, after it has been to all ap- 
pearance cured.* 

A severe degree of this ambiguous and combined form 
of Scabies is often seen in this country, in persons who 
have come from India: I have chiefly had occasion to 
observe it in children brought from that country. The 
eruption is exceedingly rank and extensive, sometimes 
even spreading to the face, and gives a more dark and 
sordid hue to the skin than the ordinary Scabies; and 
the intermixture of patches of an impetiginous character, 
where the pustules become confluent, is considerable. 
It is extremely contagious, and also obstinate in its re- 
sistance to the operation of remedies.f 

Another violent form of Scabies is excited by the con- 

* " Quxdam est etiam ejus species, quae quanquam in ipso cor- 
pore non genita sit, sed aliunde advecta, quanquam et consuetis re- 
medis primo sanata fuerit, tamen non cessat redire semel vel bis 
quotannis." Heberden, Commentar. Perhaps the Scabies her- 
petica of Sauvages may include some of these cases of S. cachec- 
tica. 

t Bonlius, in his work De Medicina Indorum, lib. iii. cap. 17, 
has described this severe disease, under the appellation of" herpes, 
seu impetigo indica," as frequent among the inhabitants of India, 
by whom it is denominated couraft, which is equivalent to our 
term itch. The cure of it, he says, is generally much neglected 
there, in consequence of a prevalent notion, that it renders a per- 
son secure from all violent diseases ; yet the itching is severe and 
incessant, and so much abrasion is produced by scratching, that 
the linen often adheres to the excoriated parts, so as not to be re- 
moved without drawing blood. — This is the Scabies indica of Sal- 
vages, spec. 6. 



SCABIES. 205 

tact of clogs, cats, hogs, and other animals, affected with 
mange. (Plate XLVI. Fig. 2.) This also extends over 
the whole body, the pustules being very rank and nume- 
rous, and more inflamed and hard at the base than in 
the ordinary eruption; the general surface of the skin is 
also rough, and of a browner hue; and the excoriations 
and abrasions more extensive, in consequence of the 
more violent and irresistible application of the nails. 

The most ordinary cause of Scabies is contagion; the 
virus being communicated by the actual contact of those 
already affected with it, or of their clothes, bedding, &c. 
especially where there is much close intercourse. It 
seems to originate, however, in crowded, close, and un- 
cleanly houses; and is, therefore, extremely prevalent 
in work-houses, jails, and hospitals, where the means of 
great cleanliness are not easily obtained, and is mostly 
seen among the families of the poor. When the conta- 
gion has been introduced, however, into families, where 
every attention to cleanliness is enforced, it will frequent- 
ly spread to all the individuals, children, and adults, and 
continue, in spite of the utmost cleanliness, until the 
proper remedies are resorted to. 

Some writers have ascribed the origin of the itch, in 
all cases, to the presence of a minute insect, breeding 
and burrowing in the skin; while others have doubted 
the existence of such an insect.* Both these opinions 

* Dr. Heberilen never saw any of these insects; and he was in- 
formed both by Baker and Canton, who excelled in the use of the 
microscope, that they had never been able to detect them. Loc 
cit. 



206 PUSTUJLffi: 

appear to be incorrect; and probably that of Sauvages 
is right, who considers the insect as generated only in 
some cases of Scabies, and therefore speaks of a Sca- 
bies vermicularis, as a separate species.* 

The existence of such an insect, in some cases of 
Scabies, has been fully demonstrated; and, although 
never able to discover it in any patient myself, I have 
seen it, in one instance, when it had been taken from 
the diseased surface by another practitioner. In fact, it 
was described in the twelfth century by Abinzoar, and 
subsequently by Ingrassias of Naples, by Gabucinus, 
Laurence Joubert, and other writers of the fifteenth and 
sixteenth centuries, who are quoted by our country- 
man, Moufet.f These writers describe the insects as 
acari, that is, very minute and almost invisible animal- 
cula, burrowing under the cuticle, and exciting small 
pustules, filled with a thin fluid, and intense itching. 
Moufet states, that they do not reside in the vesicles 
or pustules, but near them; that they are not of the 
same genus with lice, which live exterior to the cu- 
ticle; — that they are similar to the acari, or mites, of 
cheese, wax, &c. but are called ivheal-icorms in man; 
— and that when they are pressed between the nails, a 
small sound is heard. Most of these points have been 
subsequently confirmed. The insects were accurately 

* Nosol. Method, loc. cit. spec. 11. 

t See his « Theatrum Insectorum," printed in 1634, cap. 24 
'< de Syronibus, Acaris, Tineisque Animalium." 



SCABIES. 207 

ascertained and figured (by the aid of the microscope) 
by Bonomo,* in 1683, whose account was afterwards 
published by Dr. Mead,f Schwiebe, Baker, and others: 
and Linnasus, De Geer, Wichmann, &c. have since 
that period illustrated the subject of these acari sca- 
biei.J The latest authors particularly confirm the 
observation of Moufet, that the insects are not to be 
found in the pustules, but in the reddish streaks or 
furrows near them, or in the recent minute vesicles: 
but I must acknowledge my own want of success to 
discover them in any of these situations. I am disposed, 
therefore, to believe, that the breeding of these acari 
in the scabious skin is a rare and casual circumstance, 
like the individual instance of the production of a mi- 
nute pulex in prurigo, observed by Dr. Willan; and 
that the contagious property of scabies exists in the 
fluid secreted in the pustules, and not in the transfer- 
ence of insects. 

Among the remedies appropriated to the cure of 
Scabies, sulphur has long been deemed, both by the 

* See his Letter to Redi : — also Miscel. Nat. Curios, arm. x. 
dec. 2. 

t See -Philosph. Transact, vol. xxiii. for 1702. 

J See Lirii). " Exanthemata Viva," 1757 ; — and Amoenit. Acad. 
vol. iii. p. 333, and vol. v. p. 95. — Wichmann, Aetiologie der 
Kraetze, Hanover, 1786 ; also in the Lond. Med. Journal, vol. ix, 
p. 28. — DeGeer, Memoires pour servira l'Hist, des Insectes. 



2QS PUSTULE: 

vulgar and the erudite, to possess specific powers/ 
The common people treated the disease with this sub- 
stance alone, a century ago, administering it internally 
in milk, and applying it externally in butter.f In the 
less violent degrees of Scabies, and in the purulent 
species affecting the hands and wrists, perhaps no im- 
provement can be made upon this practice. The latter 
species, when it occurs in children, is often readily 
removed by the internal use of this medicine, alone, 
or in combination with a neutral salt, independently 
of any external application.! And there are few cases 
of Scabies, which will not yield to the steady employ- 
ment of the sulphur ointment, continued a sufficient 
time, and rubbed on the parts affected nightly with 
assiduity. Five or six applications are commonly suf- 
ficient for the cure of the disease: but sometimes it is 
necessary to persevere in the inunction for the space of 
a fortnight, or even longer; from which no detriment 
ensues to the constitution. 

* See Willis, Pharmaceut. Rational, part ii. sect. iii. cap. 6. 

f See Turner, De Morhis Cutaneis. 

| Writers in general agree in asserting the greater facility of 
curing the humid, than the dry forms of Scabies. But under the 
term Scabies sicca, it is obvious that they describe t«he prurigo, 
and even some scaly and furfuraceous eruptions, accompanied 
with itching, which arc often more difficult of removal than any 
variety of true Scabies. See Sauvages and Scnnert (loc. cit.), 
and Vogel, dc curand. Horn. Mprb. 



SCABIES. 209 

The disgusting odour of the sulphur,* however, 
has led practitioners to resort to various other stimu- 
lating applications, some of which have been recom- 
mended from ancient times, for the cure of scabid and 
pruriginous eruptions. Among these, the root of the 
white hellebore is possessed of considerable efficacy, 
and may be applied in the form of ointment, or in 
that of decoction. In the latter form I have generally 
found it advisable to employ a stronger decoction, than 
that which is recommended in the pharmacopoeia of the 
college. Potass, in a state of deliquescence, was a 
favourite addition to these applications with Willis and 
his predecessors; and muriate of ammonia, and some 
other saline stimulants, have been more recently used, 
and not without benefit.f The strong sulphuric acid, 
which was long ago recommended by Crolius, mixed 
with lard, and applied by external friction, has also 

* Both the smell anil sordid appearance of the sulphur oint- 
ment maybe in a considerable degree obviated by the following 
combination : 

I$> Potassse subcarbonatis §ss 
Aquae rosae Ji 

Hydrarg. sulphurati rubri § i 
Olei essent. bergamot. § ss 
Sulphuris-sublimati 

Adipis suillse aa %ix. Misce secundum artem. 
t This salt, together with hellebore, is said to constitute a 
part of a celebrated nostrum for Scabies, called the Edinburgh 
Ointment. 

»4 



210 PUSTULE: 

been employed;* and it certainly possessed the re~ 
commendations of being inodorous and comparatively 
cleanly. But independently of its corrosive action on 
the patient's clothing, it has appeared to me to be very 
uncertain in its effects. The muriate of mercury, and 
the white precipitated oxide, are both possessed of con- 
siderable efficacy in the relief of Scabies. The testi- 
monies in favour of the latter are very numerous.! It 
seems particularly well adapted to the impetiginous 
form of the disease, which is liable to be irritated by 
the more acrid applications. The muriate has pro- 
bably derived some of its remedial character from 
its efficacy in the relief of prurigo, and other erup- 
tions, accompanied by itching, with little inflamma- 
tion; but it is not altogether destitute of power in Scabies 
itself. 

A committee of French physicians reported the re- 
sult of some experiments made with the root of the 
Plumbago Europaea, (pounded and mixed with boiling 
oil,) to the Medical Society of Paris; from which they 

* See Hafenrefl'er de Cute, lib. i. cap. 14. The sulphuric acid 
was also recommended to be taken internally, as a remedy for 
Scabies, by Dr. Cothenius, who is said to have used it with 
success in the Prussian army, in 1756. See Ediu. Med. Com. 
vol. i. p. 103. But subsequent experience lias not confirmed hi& 
-cport. 

t See Willis, Vogel, Sauvages, Callisen, Ileberden, Sec. Prof. 
Selle affirms, "Scabies e contagio cxterno maxime ex parte per 
solum mere, prsecip. albi usum tollitur." Med. Clin. 191. See 
*!so Fordyce, Fragments Chirufgica. 



SCABIES. 211 

inferred, that it cured Scabies more speedily than any 
other remedy. The third or fourth inunction with this 
substance, they affirm, is generally successful.* Seve- 
ral of the continental writers recommend in strong 
terms, the formula of an " Unguentum ad Scabiem," 
prescribed by Jasser, which directs equal parts of sul- 
phate of zinc, flowers of sulphur, and laurel berries, to be 
made into a liniment with oil.f From a few trials of this 
ointment, I am disposed to believe that it is possessed of 
considerable efficacy. 

* See Memoires de la Soc. Roy. de Medicine de Paris, torn, 
iii.; also Lond. Med, Journal, vol. v. 

t See Plenck, Doctr. de MorbisCutaneis, p. 42 ; Callisen, Syst. 
Chirurg. Hodiern. 



2VJ 

fhder VI. 

VESICULM. 

The Order of Vesicles (see Definition 6) comprehend' 
seven genera. 



I. VARICELLA. 
CHICKEN-POX, SWINE-POX, ETC. 

This disease is usually so slight as to require little me 
dical assistance; but in consequence of the resemblance 
of the eruption, under some of its varieties, to the small- 
pox, it becomes important, as a point of diagnosis, to 
establish its character with accuracy. 

Although its appearances were described by writers 
on the smallpox three centuries ago, under the appella- 
tion of CrystaUi* and at a period not much later, it had 
even acquired popular names in Italy, France, and Ger- 
many, and subsequently in England ;f yet most of the 

* Vidus Vidius (De Crystallis) and Ingrassias (De Tumor, praet. 
Nat. lib. i. cap. 1.) describe these crystalli, as white shining pus- 
tules, containing lymph, nearly as large as lupine seeds, and at- 
tended with little fever : " suntque hae minus periculosae (i. e. 
than smallpox,) et saepe citra notabilem febrem infantes prehen- 
dunt." 

f We have the testimony of many writers, in proof of the prk>: 
discrimination of the vulgar, in respect to this eruptive disease. 



VARICELLA. £1$ 

systematic writers, down to the latter part of the eigh- 
teenth century, seem to have looked upon it as a variety 
of smallpox. D. Heberden, in the year 1767, pointed 
out the distinction with his accustomed perspicuity.* 
Perhaps, however, as this learned physician, in his post- 
humous work, continues to designate the disease by the 
term Variola, f the employment of the same term by the 
systematic writers above alluded to, with the epithets 

Sennertus, who was a professor at Wittemberg, at the commence- 
ment of the seventeenth century, observes, in his treatise on small- 
pox and measles, that there are other varieties, " praeter com- 
munes variolas et morbillos," which are popularly known, in Ger- 
many, by the terms Schaffsblattern (sheep -pox, or vesicles) or 
Windbocten (wind-pox.) See his Med. Pract. lib. iv. cap. 12. 
And Riverius, who was professor at Montpellier at the same pe- 
riod, speaks of the eruption as familiarly known by the common 
people in France, by the appellation of Veirolette. See his Prax. 
Med. cap ii. In Italy it was called Ravaglione. Ibid — See also 
Diemerbroeck, De Variolis et Morbis, , cap. 2. — Fuller, in his 
11 Exanthematologia," published in 1730, describes the eruption, 
and acknowledges himself indebted to the nurses for the appella- 
tion. " I have adventur'd to think," he says, " this is that which 
among our women goeth by the name of chicken-pox." p. 161. 
And it is mentioned familiarly, at Edinburgh, in 1733, as " the 
bastard or chicken-pox." See Edin. Med. Essays, vol. ii. art. 2. 
At Newcastle and in Cumberland, it is popularly known by the 
name of water jags. See Dr. Wood, in the Med. and Phys. 
Journal vol. xiii. p. 58,7iote. 

* See his paper in the Med. Transact, of the Coll. of Phys. 
vol. i. art xvii. 

t « Variola fiusilla." See his Comment, de Morbis, cap. 96. 



2li VES1CVLJE 

volaticce, spuria* &c. cannot be deemed evidence, that 
they actually considered the disease as generically the 
same with smallpox. 

The three principal varieties of chicken-pox were 
well known a century ago, and were distinguished in 
the north of England, and in some counties in Scotland, 
by the popular names of chicken-pox, swine-pox, and 
hives. Dr. Willan proposed to distinguish them, ac- 
cording to the different forms of the vesicles, by the epi- 
thets, lenticular, conoidal, and globate.f 

1. The lenticular Varicella (Plate XLVII— VIII.) 
appears, on the first day of the eruption, in the form of 
small red protuberances, not exactly circular, but tend- 
ing to an oblong figure, having a nearly flat and shining 
surface, in the centre of which a minute transparent ve- 
sicle is speedily formed. This, on the second day, is 
filled with a whitish lymph, and is about the tenth of 
an inch in diameter. On the third day the vesicles have 
undergone no change, except that the lymph is straw- 
coloured. On the fourth day, those which have not 
been broken begin to subside, and are puckered at their 

* See Vogel, dc cognoscend. et cur. Horn. Morb. § 128. (edit 
1772.) Burserius, Inst. Med. vol. ii. cap. 9. § 305. Sauvages, how- 
ever, actually makes it a species of variola, class, ii i - gen. ii. spec, 
i. V. lymphatka. 

t See his treatise " On Vaccine Inoculation," published in 
1806, sect. vii. — Dr. Fuller, above quoted, described these three 
varieties under the appellations of chicken-pox, swine-pox, and 
cry6talli, p. 161-3. 



VARICELLA. 215 

edges. Few of them remain entire on the fifth day; but 
the orifices of several broken vesicles are closed, or ad- 
here to the skin, so as to confine a little opaque lymph 
within the puckered margins. On the sixth day, small 
brown scabs appear universally in place of the vesicles. 
The scabs, on the seventh and eighth days, become yel- 
lowish, and gradually dry from the circumference to- 
wards the centre. On the ninth and tenth days, they 
fall off, leaving for a time red marks on the skin, without 
depression. Sometimes, however, the duration of the 
disease is longer than the period just stated, as fresh 
vesicles arise during two or three successive days, and go 
through the same stages as the first. 

2. In the conoidal Varicella, the vesicles rise sud- 
denly, and have a somewhat hard and inflamed border: 
they are, on the first day of their appearance, acuminat- 
ed, and contain a bright transparent lymph. On the 
second day, they appear somewhat more turgid, and are 
surrounded by more extensive inflammation; the lymph 
contained in many of them is of a light straw-colour. On 
the third day, the vesicles are shrivelled; those which 
have been broken, exhibit, at the top, slight gummy 
scabs, formed by a concretion of the exuding lymph. 
Some of the shrivelled vesicles, which remain entire, but 
have much inflammation round them, evidently contain 
on this day purulent fluid: every vesicle of this kind 
leaves after scabbing, a durable cicatrix or pit. On the 
fourth day, thin dark-brown scabs appear intermixed 



216 VESICUL^: 

with others, which are rounded, yellowish, and semi- 
transparent These scabs gradually dry and separate, 
and fall off in four or five days. A fresh eruption of 
vesicles usually takes place on the second and third day; 
and as each set has a similar course, the whole duration 
of the eruptive stage in this species of Varicella, is six 
days; the last formed scabs, therefore, are not separated 
till the eleventh or twelfth day. 

3. In the swine-pox or hives (for in the south, the 
former appellation is applied both to the second and 
third species) the vesicles are large and globated, but 
their base is not exactly circular. There is an inflam- 
mation round them, and they contain a transparent lymph, 
which, on the second day of the eruption, resembles 
milk-whey. On the third day, the vesicles subside, and 
become puckered and shrivelled, as in the two former 
species. They likewise appear yellowish, a small quan- 
tity of pus being mixed with the lymph. Some of them 
remain in the same state till the following morning; but, 
before the conclusion of the fourth day, the cuticle sepa- 
rates, and thin blackish scabs cover the bases of the 
vesicles. The scabs dry and fall off in four or five days. 

Some degree of fever generally precedes the eruption 
of Varicella for a couple of days, which occasionally 
continues to the third day of the eruption. This is 
sometimes very slight, so that it is only recollected, as 
having been previously indicated by fretfuln ess, after uV 



VARICELLA. £17 

eruption appeared.* " The eruption usually commences 
on the breast and back, appearing next on the face and 
scalp, and lastly on the extremities. It is attended, es- 
pecially in children, with an incessant tingling or itching, 
which leads them to scratch off the tops of the vesicles; 
so that the characteristics of the disease are often de- 
stroyed at an early period. Many of the vesicles thus 
broken and irritated, but not removed, are presently sur- 
rounded by inflammation, and afterwards become pus- 
tules, containing thick yellow matter. These continue 
three or four days, and finally leave pits in the skin." 

The eruption is sometimes preceded, for a few hours, 
by a general erythematous rash. It is usually fullest in 
the conoidal form of Varicella, in which the vesicles are 
sometimes coherent, or seated close together, but seldom 
confluent.f The incidental appearance of pustules, just 
mentioned, among the vesicles, sometimes occasions a 
doubt respecting the nature of the eruption. The fol- 
lowing circumstances, however, if carefully attended to, 
will afford sufficient grounds of diagnosis. 

The " vesicle full of serum on the top of the pock," 
as Dr. Heberden expresses it, on the first day of the 

* Dr. Heberden observes, " These pocks come out in many 
without any illness or previous sign." — But Dr. Willan states, « I 
do not remember to have seen any case of Varicella without some 
disorder of the constitution." Loc. cit. 

t See Dr. Willan's treatise. A case of confluent chicken-pox 3 
illustrated by a coloured engraving, was published by Mr. Ring; 
in the Med. and Phys, Journal for 1805, vol. xiv. p. HI. 

e e 



213 VESICULtE: 

eruption; — tiie early abrasion of many of these vesicles;, 
their irregular and oblong form; — the shrivelled or 
wrinkled state of those which remain entire, on the 
third and fourth day, and the radiating furrows of others, 
which have had their ruptured apices closed by a slight 
incrustation; — the general appearance of the small scabs 
on the fifth day, at which time the smallpox are not at 
the height of their suppuration, — sufficiently distinguish 
the eruption of Varicella, from the firm, durable, and 
slowly maturating pustules of smallpox. Dr. Willan also 
points out a circumstance, which is very characteristic: 
viz. " that variolous pustules, on the first and second day 
of their eruption, are small, hard, globular, red, and 
painful: the sensation of them to the touch, on passing 
the finger over them, is similar to that which one might 
conceive would be excited by the pressure of small 
round seeds under the cuticle. In the Varicella almost 
every vesicle has, on the first day, a hard inflamed mar- 
gin; but the sensation communicated to the finger, in 
this case, is like that from a round seed, flattened by 
pressure." 

Dr. Willan remarks Kkewise, that, as the vesicles of 
the chicken-pox appear in succession, during three or 
four days, different vesicles will be at once in different 
states of progress: and if the whole eruption, on the 
face, breast, and limbs, be examined on the fifth or sixth 
days, every gradation of the progress of the vesicles will 
appear at the same time. But this circumstance cannofr 



VARICELLA. 219 

take place in the slow and regulated progress of the 
smallpox. 

When the globated vesicles of the hives appear, (ami 
they are occasionally intermixed both with the lenticu- 
lar and conoidal vesicles,) they afford a ready distinc- 
tion from the smallpox, to the pustules of which they 
bear little resemblance. 

There is a variety of smallpox, which is occasionally 
produced by variolous inoculation, and which has usual- 
ly appeared where vaccination had only partially in- 
fluenced the constitution: this commonly dries up on 
the sixth or seventh day, without maturation. But the 
small, hard, tubercular form of this eruption, is suffi- 
ciently distinct from every form of the vesicles of 
chicken-pox. 

It is unnecessary to say any thing respecting the 
treatment of Varicella; since nothing in general is re- 
quisite beyond an attention to the state of the bowels, 
and abstinence from animal diet for two or three days. 

From some experiments made, in his own family, by 
an eminent surgeon, and from others performed at the 
Smallpox Hospital, it appears, that Varicella is commu- 
nicable by inoculation with the lymph of the vesicles; — 
that it may be introduced while the constitution is under 
the influence of vaccination, without impeding the pro- 
gress of the latter, or being itself interrupted; — that 
smallpox, inoculated during the eruptive fever of Vari- 
cella, proceeds regularly in its course, without occa- 
sioning any deviation in that of the latter;-— but that, 



220 VESICULjE 

when variolous and varicellous virus is inserted at the 
same time, the smallpox proceeds through its course, 
while that of the chicken-pox is in a greaf^degree inter- 
rupted.* But the experiments have not been sufficient- 
ly numerous to warrant the accuracy of these general 
conclusions. 

JI. VACCINIA. 

As the subject of Cow-pox has been amply treated 
of, in publications that are in every body's hands, it will 
be unnecessary for me to enter into a minute detail 
upon it here. It is now well known, that the cha- 
racteristic of this eruption (the discovery of which, as 
a preventive of the pestilential smallpox, has conferred 
immortality on the name of Jenner) is a semi-trans- 
parent, pearl-coloured vesicle, with a circular or some- 
what oval base, its upper surface, until the end of the 
eighth day, being more elevated at the margin than in 
the centre, and the margin itself being turgid, shining, 
and rounded, so as often to extend a little over the line 
of the base.f This vesicle is filled with clear lymph, con- 
tained in numerous little cells, that communicate with 
each other. After the eighth or ninth day, from the 
insertion of the virus, it is surrounded by a bright red, 
circumscribed areola, which varies in its diameter, in 
different cases, from a quarter of an inch to two inches, 

* See Dr. Willan's Treatise on Vaccination, pp. 97 — 103. 
■i See the Plate, fig. 6 7. 



VACCINIA. 221 

and is usually attended with a considerable tumour and 
hardness of the adjoining cellular membrane. This 
areola declines on the eleventh and twelfth day; the 
surface of the vesicle then becomes brown in the centre: 
and the fluid in the cells gradually concretes into a hard 
rounded scab, of a reddish brown colour, which at length 
becomes black, contracted, and dry, but is not detached 
till after the twentieth day from the inoculation. It 
leaves a permanent circular cicatrix, about five lines in 
diameter, and a little depressed, the surface being marked 
with very minute pits or indentations, denoting the num- 
ber of cells of which the vesicle had been composed.* 

A vesicle, possessing these characters, and passing 
through these regular gradations, whether accompanied 
by any obvious disorder of the constitution or not, ef- 
fectually and permanently secures the individual from 
the danger, and almost universally from the contagion of 
smallpox.f 

* See Dr. Willau's Treatise on Vaccination, p. 9. 

t At the end of the sixteenth year from the promulgation of the 
discovery, this trulh remains in full force: the very exceptions to 
it (and what result of human research is free from exceptions?) 
may be said, without a solecism, to corroborate it. For, n the 
very small number of cases, (such as that of the son of Earl 
Grosvenor,) where an extensive eruption of smallpox has occurred 
subsequent to vaccination, the controlling influence of the cow-pox 
has been invariably and strikingly manifested, by the sudden inter- 
ruption of the smallpox in the middle of its course, and the rapid 
convalescence of the patient. 



222 VESICUL^: 

It is requisite, therefore, that the vaccinator should 
attend to the irregular appearances, which are produced 
either by the insertion of matter, that is so far corrupted 
or deteriorated, as to be incapable of exciting the perfect 
disease, or by the inoculation of proper lymph, under 
certain circumstances of the habit, which interfere with 
its operation, and which will be mentioned presently. 

There is no uniform appearance, which is character- 
istic of imperfect vaccination: on the contrary, three 
varieties of irregularity have been noticed; namely, pus- 
tules,* ulcerations, and vesicles of an irregular form. 
The pustule, which is sometimes produced instead of 
the proper vaccine vesicle, is more like a common fes- 
tering boil, occasioned by a thorn, or any other small 
extraneous body sticking in the skin, according to Dr. 
Jenner; and it throws out a premature efflorescence, 
which is seldom circumscribed.! It is, as Dr. Willan 
has stated, of a conoidal form, and raised upon a hard 
inflamed base, with diffuse redness extending beyond it: 
it increases rapidly from the second to the sixth day, 
and is usually broken before the end of the latter, when 

* The pustules here mentioned occur on the inoculated part. 
Those pustules, which appeared over the body, in the first experi- 
ments with the vaccine virus made, in the Smallfiox Hospital, by 
Dr. Woodville, and which puzzled the early vaccinators, were 
-subsequently proved, and admitted by Dr. Woodville himself, to 
have been genuine smallpox, the result of the contagion of the 
nlace. 

f See Med. and Physical Journ. vol. xii. for Aug. 1804, p. 98. 



vaccinia. 223 

an irregular, yellowish-brown scab succeeds.* Ulcerctr 
lion, occupying the place of a regular vesicle, must be 
obviously incorrect: it probably originates from the pus- 
tules just mentioned, which, on account of the itching 
that is excited, are sometimes scratched off at a very 
early period; or, being prominent and tender, are rea- 
dily injured and exasperated by the friction of the 
clothes, &c.f 

With respect to the irregular vesicles, " which do not 
wholly secure the constitution from the smallpox," Dr. 
Willan has described and figured three sorts. " The 
first is a single pearl-coloured vesicle, set on a hard dark 
red base, slightly elevated. It is larger and more globate 
than the pustule above represented, but much less than 
the genuine vesicle: its top is flattened, or sometimes a 
little depressed, but the margin is not rounded or pro- 
minent. — The second appears to be cellular, like the 
genuine vesicle; but it is somewhat smaller, and more 
sessile, and has a sharp angulated edge. In the first the 
areola is usually diffuse, and of a dark rose-colour; in the 
second, it is sometimes of a dilute scarlet colour, radiat- 

* This premature advancement was pointed out by Dr. Jenner 
as a characteristic of the irregular pock, in his Paper of Instruc- 
tions for Vaccine Inoculation, at an early period of the practice. 
He also justly remarked, in respect to the" soft, amber-coloured" 
scab, left by these pustules, that " fmrulent matter cannot form a 
scab so hard and compact as limjnd matter." loc. cit. p. 99, note, 
In other words, that the scab succeeding a fiustule is less hard arsd 
compact than the scab which forms on a vesicle. 

t Dr. WiUan, loc. cit. 



224 VESICULJE: 

ed, and very extensive, as from the sting of a wasp 
The areola appears (earlier) round these vesicles, on the 
seventh or eighth day after inoculation, and continues 
more or less vivid for three days, during which time the 
scab is completely formed. The scab is smaller and 
less regular than that which succeeds the genuine vesi- 
cle; it also falls off much sooner, and, when separated, 
leaves a smaller cicatrix, which is sometimes angulated. 
The third irregular appearance is a vesicle without an 

areola."* 

There are two causes, as I have intimated above, for 

these imperfect inoculations; the one is the insertion of 

* It appears to mc that Mr. Bryce, in his able and valuable work 
on the Inoculation of Cow-pox, has, without any sound reason, im- 
pugned these observations upon the " irregular vesicles," and 
considered the introduction of the terms as productive of" much 
injury to the true interests of vaccination," and as serving " to 
screen ignorance or inattention in the operator:" and that his own 
reasoning, which amounts to nothing more than a hypothetical ex- 
planation (and consequently an admission) of the fact, is irrelevant. 
He divides the whole " into constitutional and local ;" but at the 
same time admits, that he knows no criterion by which they are to 
be distinguished, save the ultimate security against smallpox pro- 
duced by the one, and not by the other. (Appendix, no. x. p. 114, 
edit. 2d.) Now this is surely to screen ignorance and inattention, 
by representing minute observation of appearances as unnecessa- 
ry. However, he more than compensates for this error of logic, 
by the ingenious test of a double inoculation, at the interval of five 
or six days, which he has established, and which is sufficiently 
mechanical, to be employed without any unusual nicety of obser- 
vation or tact. 



VACCINIA. 225 

effete or corrupted virus, and the other the presence of 
certain cutaneous eruptions, acute and chronic. 

The lymph of the vaccine vesicle becomes altered in 
its qualities soon after the appearance of the inflamed 
areola; so that, if it be taken for the purposes of inocu- 
lation after the twelfth day, it frequently fails to produce 
any effect whatever; and in some cases it suddenly ex- 
cites a pustule, or ulceration, in others an irregular vesi- 
cle, and in others erysipelas. If taken when scabs are 
formed over the vesicles, (as in the case of the pustules 
of smallpox,) the virus is occasionally so putrescent and 
acrid, that it excites the same violent and fatal disease, 
which arises from slight wounds received in dissecting 
putrid bodies. 

Again, the lymph, although taken from a perfect vesi- 
cle on the sixth, seventh, or eighth day, may be so injur- 
ed before its application, by heat, exposure to the air, 
moisture, rust, and other causes,* as to be rendered in- 
capable of exciting the true disease. 

The most frequent cause of these imperfections, how- 
ever, seems to be the presence of chronic cutaneous 
eruptions, or the concurrence of eruptive fevers, or even 
of other febrile diseases. The chronic cutaneous dis- 
eases, which sometimes impede the formation of the ge- 
nuine vaccine vesicle, have been described by Dr. Jen- 
ner under the ordinary indefinite term herpes,f and tinea 

* Dr. Willan, loc. cit. 

t See his letter to Dr. Marcet, Med. and Phys. Journ. for May, 
1803 ; also the same Journal for Aug. 1804, 
Ff 



22b VESICUL/E 

capitis. In the more accurate phraseology of Dr. Wif- 
lan, they are herpes (including the shingles and vesicular 
ring-worm,) psoriasis and impetigo (the dry and humid 
tetter,) the lichen, and most frequently the varieties of 
porrigo, comprising the contagious eruptions denominat- 
ed by authors crusta lactect, area, achores, and favi. 
Dr. Willan thinks that the itch and prurigo likewise 
have the same influence. 

Of the interference of the eruptive fevers, measles, 
scarlet fever, and chicken-pox, with the progress of the 
vaccine vesicle, when they occur soon after vaccination- 
numerous instances have been recorded. The suspen- 
sion of its progress, indeed, would be expected, under 
such circumstances, from the known facts respecting 
the reciprocal action of these contagious fevers on each 
other. But the action of the vaccine virus is not only 
suspended by these fevers, so that the vesicle is very 
slow in its progress, and the areola not formed till after 
the fourteenth day or later, and sometimes not at all: 
but it is occasionally rendered altogether inefficient 
Even typhus fever and the influenza have been ob- 
served to produce a similar interruption in the progress 
of vaccination. 

Finally, the vesicle, without an areola, takes place if 
the person inoculated have previously received the in- 
fection of smallpox, or if he be affected with some other 
contagious disease during the progress of vaccination.* 

* Dr. Willars, loc.cit- 



HERPES. 221 

Other irregularities may probably have occurred. At 
all events, though the constitution is sometimes fully se- 
cured from the infection of smallpox, even by the irre- 
gular vesicles; yet, as it is more commonly but imper- 
fectly guarded by such vesicles, the propriety of Dr. 
Jenner's caution is obvious; that, "when a deviation 
arises, of whatever kind it may be, common prudence 
points out the necessity of re-inoculation."* 



III. HERPES.f 

This appellation is here limited to a vesicular disease, 
which, in most of its forms, passes through a regular 
course of increase, maturation, and decline, and termi- 
nates in about ten, twelve, or fourteen days. The ve- 
sicles arise in distinct but irregular clusters, which com- 
monly appear in quick succession, and they are set near 

* Paper of Instructions, before quoted. 

t Actuarius explains the origin of this term, as well as of the 
application of the word^re, to these hot and spreading eruptions. 
" Herp.es dicitur eo quod videatur ; ep7retv (quod est serfiere per 
sumraam cutem,) modo hanc ejus partem, modo proximam oc- 
cupans, quod semper, priore sanata, propinqua ejus vitium exci- 
piat ; non secus quam ignis qui proxima quaeque depascitur, ubi 
ea quje prius accensa erant, deficiente jam materia idonea, prius 
quoque extinguuntur." Meth. Med. lib. ii. cap. 12. — From this 
creeping progress, the disease was called Formica by the Ara- 
bians, 



228 VESICUL^:. 

together, upon an inflamed base, which extends a little 
way beyond the margin of each cluster. The eruption 
is preceded, when it is extensive, by considerable consti- 
tutional disorder, and is accompanied by a sensation of 
heat and tingling, sometimes by severe deep-seated pain, 
in the parts affected. The lymph of the vesicles, which 
is at first clear and colourless, becomes gradually milky 
and opaque, and ultimately concretes into scabs; but, in 
some cases, a copious discharge of it takes place, and te- 
dious ulcerations ensue. The disorder is not contagious 
in any of its forms. 

The ancients, although they frequently mention Her- 
pes, and give distinctive appellations to its varieties, 
have no where minutely described it: hence their fol- 
lowers have not agreed in their acceptation of the term.* 

* Although some of the ancients are more anxious to point out 
the nature of the morbid humour, to which the Herpes was to 
be imputed, than to describe its symptoms; yet lypst of them 
speak of small bulla, or phlyctxne-, as characteristic of the erup- 
tion. (Sec Galen de Tumoribus pi set. Naturam; — Ae:ius, tc- 
trab. iv. serin, ii. rap. 60; Paulus, lib. iv. cap. 20; — Actuarius, 
lib. ii. cap. 12.) Again, Scribonius Largus speaks of the most 
remarkable form of this vesicular disease (the zoster, or shin- 
gles.) as a species of Herpes. " Zona quam Graeci e^t* di- 
cunt." See Scribon. dc Compos. Mcdicam. cap. 13. Indescrib- 
ing the appearances of this disease, under the appellation of Ignis 
sacer. Celsus has properly characterized it by the numerous and 
congregated eruption, the small and nearly equal size of the vesi- 
cles, and the situations which it most frequently occupies, &c. 
'< Exasperatumque per pusulas continuas, quarum nulla alteia. 



HERPES. 229 

It has been principally confounded with erysipelas, on 
the one hand, and with eczema, impetigo,* and other 
slowly spreading eruptions, on the other. But if the 
preceding character be well considered, the diagnosis 
between these affections and Herpes will be sufficiently 
obvious. From erysipelas it may be distinguished by 
the numerous, small, clustering vesicles, by the natural 
condition of the surface in the interstices between the 
clusters, and by the absence of redness and tumefaction 
before the vesicles appear: and from the chronic erup- 
tions just alluded to, by the purely vesicular form of the 
cuticular elevations in the commencement, by the regu- 
larity of their progress, maturation, and scabbing, and by 
the limitation of their duration, in general, to a certain 
number of days. 

The ancient division of Herpes into three varieties, 
miliary, («yw*s,) vesicular ($a«*t*/v«^s,) and eroding 
(erttopuvos,) may be properly discarded: for there appears 
to be no essential distinction between the first two, which 
differ only in respect to the size of the vesicles; and the 

major est, seel plurims perexiguae : in his semper fere pus, ct 
saepe rubor cum calore est: serpitque id nonnunquam sanescente 
eo quod primum viliatum est ; nonnunquam etiam exulcerato, 
ubi, ruptis pustulis, ulcus continuatur, humorque exit, qui esse 
inter saniem et pus videri potest. Fit maxime in pectore, aut la- 
teribus, aut emineetibus partibus, praecipueque in plantis." Lib. 
v. cap. 28. § 4. 

* See Dr. Cullen's definition of Herpes. Noso). Method, gen, 
147. 



230 VESICULjE 

last is incorrectly classed with Herpes, being perhaps re- 
ferable rather to pompholyx, or those larger bullae, 
which arise in bad habits of body, and are followed by 
ill-conditioned ulcerations of the skin.* The various 
appearances of Herpes may be comprehended under the 
six following heads. 

1. Herpes phlyctcenodes. (Plate XLIX.) This spe- 
cies of the eruption, including the miliary variety above 
mentioned, is commonly preceded by a slight febrile 
attack for two or three days. The small transparent 
vesicles then appear, in irregular clusters,! sometimes 

* Celsus has, in fact, made this distinction between the Herpes 
esthiomenos and the proper Herpes, ranking the latter under the 
head of Ignis sacer ; a term which most of the translators of the 
Greek writings have incorrectly substituted for erysipelas. 
Whereas he speaks of the H. esthiomenos as a deep spreading 
ulcer, of a cancerous character. "Fit ex his ulcus quod tgxvra. 
i-s-fl/OjWfvov Giseci vocant, quia celeriter serpendo penetrandoque 
usque ossa, corpus vorat. Id ulcus inaequale est, coeno simile, in- 
estque multus humor glutinosus, odor intolerabins, majorque 
quam pro modo ulceris inflammatio. Utrumqut. (scil. S-ypiupx et 
efTTtii) sicut omnis cancer, fit maxime in senibus, vel iis quorum 
corpora mali habitus sunt." Celsus, de Medicina, lib. v. cap. 28. 
—See also Sennert. Pract. lib. v. part. i. cap. 17. 

t Occasionally, however, the patches are of a regular circular 
form, and the arete are completely covered with crowded vesicles ; 
and in these cases the constitution is more violently disordered, 
and the heat and pain attending the eruption, amounting to a sen- 
sation of actual burning or scalding, are more severe, than in any 



HERPES. £31 

containing colourless, and sometimes a brownish lymph; 
and, for two or three days more, other clusters succes- 
sively arise near the former. The eruption has no cer- 
tain seat: sometimes it commences on the cheeks or 
forehead, and sometimes on one of the extremities; and 
occasionally it begins on the neck and breast, and gra- 
dually extends over the trunk to the lower extremities, 
new clusters successively appearing for nearly the space 
of a week. It is chiefly the more minute or miliary va- 
riety which spreads thus extensively; for those which, 
at their maturity, attain a considerable size and an oval 
form,* seldom appear in more than two or three clusters 
together; and sometimes there is only a single cluster. 
The included lymph sometimes becomes milky or opake 
in the course of ten or twelve hours; and about the 
fourth day, the inflammation round the vesicles assumes 
a duller red hue, while the vesicles themselves break, 
and discharge their fluid, or begin to dry and flatten, 
and dark or yellowish scabs concrete upon them. These 
fall off about the eighth or tenth day, leaving a reddened 
and irritable surface, which slowly regains its healthy 
appearance. As the successive clusters go through a 

other form of Herpes. To this variety of the eruption more par- 
ticularly the popular appellation of nirles has been given. 

* One of Alibert's best plates contains a representation or a ve- 
sicular disease of the face and neck, which might appear to be re- 
ferable to this species of Herpes; but, from his description of the 
disease, it is obviously a case of pompholyx. He calls it " Dartre 
phlyctenoide confluente." See his plate 23. 



2S2 VESICULiE 

similar course, the termination of the whole is not com- 
plete before the thirteenth or fourteenth day. 

The disorder of the constitution is not immediately 
relieved by the appearance of the eruption, but ceases 
as the latter proceeds. The heat, itching, and tingling 
in the skin, which accompany the patches as they suc- 
cessively rise, are sometimes productive of much rest- 
lessness and uneasiness, being aggravated especially by 
external heat, and by the warmth of the bed. 

The predisposing and exciting causes are equally ob- 
scure. The eruption occurs in its miliary form, and 
spreads most extensively, (sometimes over the greater 
portion of the surface of the body,) in young and robust 
people, who generally refer its origin to cold. But it 
is apt to appear, in its more partial forms, in those per- 
sons who are subject to headaches, and other local pains, 
which are probably connected with derangements of the 
chylopoetic organs. 

The same treatment is requisite for this as for the 
following species. 

2. Herpes zoster* (Plate L.) This form of the 
eruption, which is sufficiently known to have obtained 

* Zua-TTjf, Zmvt, a belt. These terms have been applied to this 
form of Herpes, from the situation which it always occupies on the 
trunk of the body. It has been called simply zoster (see Pirn. Nat. 
Hist. lib. xxvi. cap. 11.) and zona, or zona ignea, Sec. by different 
writers; and its symptoms may be recognised, as I have slated 
above, in the first species of sacer ignis, described by Celsus. The 



HERPES. 263 

a popular appellation, the shingles* is very uniform in 
its appearances, following a course similar to that of 
smallpox, and the other exanthematic fevers of the no- 
sologists. It is usually preceded for two or three days 
by languor and loss of appetite, rigours, headache, sick- 
ness, and a frequent pulse, together with a scalding heat 
and tingling in the skin, and shooting pains through the 
chest and epigastrium. Sometimes, however, the pre- 
cursory febrile symptoms are slight and scarcely noticed, 
and the attention of the patient is first attracted by a 
sense of heat, itching, and tingling, in some part of the 
trunk, where he finds several red patches of an irregu- 

disease has been described with different degrees of accuracy, by 
Tulpius (Obs. Med. lib. Hi. cap. 44,) Hoffmann (Med. Syst. Rat 
torn. iv. part. i. cap. 13. § 6. and obs. 6,) De Haen (De Divis. 
Febrium, p. 112, &c.) Callisen (Syst. Chirurg. Hod. torn. i. p 424,) 
Burserius (Inst. Med. Pract. torn. ii. cap. 3,) and others. Sauvages 
has included it under two genera, with the appellations of erysi- 
pelas zoster and Herpes zoster. (Nosol. Method, class, iii. gen. 7. 
and class, i. gen. 7.) Dr. Cullen has classed it with the former 
disease, under the title of erysipelas fihlyct anodes; but at the same 
time expresses a doubt of the propriety of this classification. 
(Nosol. Meth. gen. xxxi. spec. 2.) 

M. Alibert has given an indifferent representation of Herpes 
zoster, plate 24, under the title of" Dartre phiyctenoide en zone." 

* Is this a corruption from the Latin, cingulum ? Johnson held 
the affirmative : and it seems not less distinctly deducible from this 
word, than the vulgar terms quinsey and megrim^ from their Greek 
roots cynanche and hemicrania ; except that the latter had received 
a previous corruption by the French, in esquinancie and migraine^ 
from which we doubtless took our words. 



2U VESICULjE: 

lar form, at a little distance from each other, upon each 
of which numerous small elevations appear, clustered to- 
gether. These, if examined minutely, are found to be 
distinctly vesicular; and, in the course of twenty-four 
hours, they enlarge to the size of small pearls, and are 
perfectly transparent, being filled with a limpid fluid. 
The clusters are of various diameter, from one to two, 
or even three inches, and are surrounded by a narrow 
red margin, in consequence of the extension of the in- 
flamed base a little beyond the congregated vesicles. 
During three or four days, other clusters continue to 
arise in succession, and with considerable regularity; 
that is, nearly in a line with the first, extending always 
towards the spine at one extremity, and towards the 
sternum, or linea alba of the abdomen, at the other, most 
commonly round the waist like half a sash, but some- 
times like a sword-belt across the shoulder.* 

* " Mac tamen perpetua lege," says De Haen, " ut ab anteriore 
parte r.unquam lineam albam, nun(|uam a postica spinam, tran- 
scenderent." (Dc Divis. Febrium, p. 112) This observation, 
however, is not without exceptions; although the rarity of the oc- 
currence probably gave rise to the popular apprehension, which is 
as old as Pliny, that if the- eruption completed the circle of the body, 
it would be fatal. " Zoster ppellatur, et enecat, si cinxerit." 
^Plin. loc. cit.) I have seen the clusters extend across the linea alba 
in front ; and Turner asserts, that he has more than once observed 
it to surround the body. (On Dis. of the Skin, chap. v. p. 80.) 
Dr. Russel (De Tabe glandulari, hist. 33) and Tulpius (Obs 
Med. lib. iii. cap. 44,) also contradict the affirmation of Pliny. 



HERPES,. 235 

While the new clusters are appearing, the vesicles of 
the first begin to lose their transparency, and on the 
fourth day acquire a milky or yellowish hue, which is 
soon followed by a bluish, or livid colour of the bases 
of the vesicles, and of the contained fluid. They now 
become somewhat confluent, and flatten or subside, so 
that the outlines of many of them are nearly obliterated. 
About this time they are often broken, and for three or 
four days discharge a small quantity of a serous fluid; 
which at length concretes into thin dark scabs, at first 
lying loosely over the contained matter, but soon be- 
coming harder, and adhering more firmly, until they fall 
off about the twelfth or fourteenth day. The surface 
of the skin is left in a red and tender state; and where 
the ulceration and discharge have been considerable, nu- 
merous cicatrices or pits are left. 

As all the clusters go through a similar series of 
changes, those which appeared latest, arrive at their 
termination several days later than the first; whence 
the disease is sometimes protracted to twenty or even 
twenty-four days, before the crusts exfoliate. In one 
or two instances, I have seen the vesicles terminate in 
numerous small ulcers, or suppurating foramina, which 
continued to discharge for many days, and were not all 
healed before the end of the fourth week. 

The febrile symptoms commonly subside when the 
eruption is completed; but sometimes they continue 
during the whole course of the disease, probably from 
the incessant irritation of the itching and smarting con- 



SSfl VESICUL7E: 

nected with it. In many instances, the most distressing 
part of the complaint is an intense darting pain, not su- 
perficial, but deep-seated in the chest, which continues 
to the latter stages of the disease, and is not easily allay- 
ed by anodynes:* sometimes this pain precedes the erup- 
tion. 

Although the shingles commonly follow the regular 
course of fever, eruption, maturation, and decline, with- 
in a limited period, like the eruptive fevers, or exanthe- 
mata of the nosologists;f yet the disorder is not, like the 
latter, contagious, and may occur more than once in the 
same individual. J The disease, on the whole, is slight: 
it has never, in any instance that I have witnessed, ex- 
hibited any untoward symptom, or been followed by 

* Hoffmann observes, « Inde quidem symptomata remiserunt, 
excepto exquisito ardente, dolore, qui tantus erat, ut nee somnum 
capere, nee locum affectum contingere posset." Med. Syst. Rat. 
torn. iv. part. i. cap. 13. § 6. obs. vi. 

t The regularity and brevity of its course have not been suffi- 
ciently attended to. Burserius has, however, observed, "Zoster 
acutua et brevis ut plurimum morbus est ; nam, quamquam Lor- 
ryus et chronicum, et interdum epidemicum esse existimet, (quod 
de igne sacro late sumpto fortasse ei concedendum est) hanc spe- 
ciem tamen diutinam non vidi." Inst. Med. Pract. torn. ii. cap. 3. 
§52. 

\ In the course of my attendance at the Public Dispensary, dur- 
ing twelve years, between thirty and forty cases of shingles have 
occurred, none of which were traced to a contagious origin, or oc 
casioned the disease in other individuals. 



HERPES. 23*7 

much debility: in the majority of cases, it did not con- 
fine the patients to the house.* 

The causes of the shingles are not always obvious. 
Young persons from the age of twelve to twenty-five are 
most frequently the subjects of the disease, although the 
aged are not altogether exempt from its attacks, and suf- 
fer severely from the pains which accompany it. It is 
most frequent in the summer and autumn, and seems 
occasionally to arise from exposure to cold, after violent 
exercise. Sometimes it has appeared critical, when su- 
pervening to bowel-complaints, or to the chronic pains 
of the chest remaining after acute pulmonary affec- 
tions. Like erysipelas, it has been ascribed by some 
authors to paroxysms of anger. f 

It is scarcely necessary to speak of the treatment of 
a disorder, the course of which scarcely requires to be 
regulated, and cannot be shortened, by medicine. Gen- 
tle laxatives and diaphoretics, with occasional anodynes, 
when the severe deep-seated pains occur, and a light 
diet, seem to comprise every thing that is requisite in 

* Some authors, as Platner and Hoffmann, have deemed the zos' 
ter a malignant and dangerous disease: and Langius (Epist. Med. 
p. 110.) has mentioned two fatal cases occurring in noblemen. 
But they have apparently mistaken the disease. Lorry, Burserius, 
Geoffroy, and others, (Hist- de la Soc. Roy. de Med. ann. 1777-8) 
more correctly assert that it is free from danger. 

t See Schwartz Diss, de Zona serpiginosa, Halse, 1745 ; he saw 
three instances, which followed violent fits of passion, p. 17. — and 
Plenck affirms that he saw it occur twice after violent anger, and 
a copious potation of beer. (De Morb. cutan. p. 28.) 



238 VESICULjE: 

the cure. Experience altogether contradicts the cau- 
tionary precepts, which the majority of writers, even 
down to Burserius, have enjoined, in respect to the ad- 
ministration of purgatives, and which are founded en- 
tirely upon the prejudices of the humoral pathology. 

In general, no external application to the clustered 
vesicles is necessary: but when they are abraded by the 
friction of the clothes, a glutinous discharge takes place, 
which occasions the linen to adhere to the affected 
parts, producing some irritation: under these circum- 
stances, a little simple ointment may be interposed, to 
obviate that effect. With the view of clearing off the 
morbid humours, the older practitioners cut away the 
vesicles, and covered the surface with their unguents,* 
or even irritated it with the nitrico-oxyd of mercury, not- 
withstanding the extreme tenderness of the parts. f 
These pernicious interruptions of the healing process 
probably gave rise to ulceration, and prolonged the du- 
ration of the disease, and thus contributed to mislead 
practitioners, in their views respecting its nature. 

3. Herpes circinatus. (Plate LI. Fig. 1.) This form 
of the Herpes is vulgarly termed a ringworm, and is, in 

* See Turner on Dis. of the Skin, chap. 5. 

t " Ilia autem ut inspicio," says Dr. Russel, " vesiculis depres- 
ses, et minime tumentibus, at livescentibus inclucta esse, (the na- 
tural decline of the eruption) atque acrem quendam ichorem sub- 
stare cerno, proinde secantur vesiculae, et prae dpitato rubro, cum 
unguento aur. et cerato, ut medicamenta fixa .tque immota ema- 
nerent, curantur." De Tabe glandulari, hist. 33. 



HERPES. 239 

this country, a very slight affection, being unaccompa- 
nied with any disorder of the constitution. It appears 
in small circular patches, in which the vesicles arise only 
round the circumference: these are small, with mode- 
rately red bas'es, and contain a transparent fluid, which 
is discharged in three or four days, when little promi- 
nent dark scabs form over them. The central area, in 
each vesicular ring, is at first free from any eruption; 
but the surface becomes somewhat rough, and of a dull 
red colour, and throws off an exfoliation, as the vesicu- 
lar eruption declines, which terminates in about a week 
with the falling off of the scabs, leaving the cuticle red 
for a short time. 

The whole disease, however, does not conclude so 
soon: for there is commonly a succession of the vesi- 
cular circles, on the upper parts of the body, as the face 
and neck, and the arms and shoulders, which have 
occasionally extended to the lower extremities, pro- 
tracting the duration of the whole to the end of the 
second or third week. No inconvenience, however, 
attends the eruption, except a disagreeable itching and 
tingling in the patches. 

The herpetic ringworm is most commonly seen in 
children, and has been deemed contagious. It has 
sometimes, indeed, been observed in several children, 
in one school or family, at the same time: but this was 
most probably to be attributed to the season, or some 
other common cause; since none of the other species 
of Herpes are communicable by contact. It is scarcely 



240 VESICULJE: 

necessary to point out here the difference between this 
vesicular ringworm, and the contagious pustular erup- 
tion of the scalp and forehead, which bears a similar 
popular appellation.* 

The itching and tingling are considerably alleviated 
by the use of astringent and slightly stimulant applica- 
tions, and the vesicles are somewhat repressed by the 
same expedients. It is a popular practice to besmear 
them with ink: but solutions of the salts of iron, cop- 
per, or zinc, or of borax, alum, &c. in a less dirty form, 
answer the same end. 

Another form of Herpes circinatus sometimes oc- 
curs, in which the whole area of the circles is covered 
with close set vesicles, and the whole is surrounded by 
a circular inflamed border. The vesicles are of a con- 
siderable size, and filled with transparent lymph. The 
pain, heat, and irritation in the part are very distressing, 
and there is often a considerable constitutional disturb- 
ance accompanying the eruption. One cluster forms 
after another in rapid succession on the face, arms, and 
neck, and sometimes on the day following on the trunk 
and lower limbs. The pain, feverishness, and in- 
quietude do not abate till the sixth day of the eruption, 
when the vesicles flatten, and the inflammation sub- 
sides. On the ninth and tenth days a scabby crust be- 
gins to form on some, while others dry, and exfoliate; 
the whole disease terminating about the fifteenth day. 

* See Porrigo scutulata, above, p. 171. 



HERPES. 24 1 

All the forms of Herpes appear to be more severe 
in warm climates, than in our northern latitudes; and 
the inhabitants of the former are liable to a variety of 
herpetic ringworm, which is almost unknown here. 
This variety diners materially from the preceding in 
its course, and is of much greater duration. For it 
does not heal with the disappearance of the first vesicles, 
but its area continually dilates by the extension of the 
vesicular margin. The vesicles terminate in ulcera- 
tions, which are often of a considerable depth; and 
while these undergo the healing process, a new circle 
of vesicles rises beyond them, which passes through a 
similar course, and is succeeded by another circle exte- 
rior to itself: and thus the disease proceeds, often to a 
great extent, the internal parts of the ring healing, as 
the ulcerous and vesicular circumference expands.* 

4. Herpes labialis. A vesicular eruption upon the 
edge of the upper and under lip, and at the angle of 
the mouth, sometimes forming a semi-circle, or even 
completing a circle round the mouth, by the successive 
rising of the vesicles, is very common, and h«s been 
described by the oldest writers. At first the vesicles 

* Celsus appears to have described this form of Herpes, as his 
second species of Ignis sacer. " Alterum autem est in summae 
cutis exulceratione, sed sine altitudine, latum, sublividum, inaequa- 
liter tamen ; mediumque sanescit, extremis procedentibus ; ac 
saepe id, quod jam sanum videbatur, iterum exulceratur," &c« 
loc. cit. $ 4. 

« h 



VESICUL/E: 

contain a transparent lymph, which in the course of 
twenty-four hours becomes turbid, and of a yellowish 
white colour, and ultimately assumes a puriform ap- 
pearance. The lips become red, hard, and tumid, as 
well as sore, stiff, and painful, with a sensation of great 
heat and smarting, which continues troublesome for 
three or four days, until the fluid is discharged, and 
thick, dark scabs are formed over the excoriated parts. 
The swelling then subsides, and, in four or five days 
more, the crusts begin to fall off; the whole duration 
being, as in the other herpetic affections, about ten or 
twelve days. 

The labial Herpes occasionally appears as an idio- 
pathic affection, originating from cold, fatigue, &c, and 
is then preceded for about three days by the usual fe- 
brile symptoms, shiverings, headache, pains in the limbs 
and the stomach, with nausea, lassitude, and languor. 
Under these circumstances a sort of herpetic sore-throat 
is sometimes connected with it; a similar eruption of 
inflamed vesicles taking place over the tonsils and uvula, 
and producing considerable pain and difficulty of deglu- 
tition. The internal vesicles, being kept in a state of 
moisture, form slight ulcerations when they break; but 
these heal about the eighth and ninth days, while the 
scabs are drying upon the external eruption. 

The Herpes labialis, however, occurs most frequent- 
ly in the course of diseases of the viscera, of which it 
is symptomatic, and often critical; for these diseases 
are frequently alleviated as soon as it appears. Such an 



HERPES. 24S 

occurrence is most common in bilious fevers, in cho- 
lera, and dysentery, in peritonitis, peripneumony, and 
severe catarrhs; but it is not unfrequent in continued 
malignant fevers, and even in intermittents.* 

5. Herpes prceputialis. (Plate LI. Fig. 2.) This lo- 
cal variety of Herpes was not noticed by Dr. Willan; 
but it is particularly worthy of attention, because it oc- 
curs in a situation, where it is liable to occasion a prac- 
tical mistake of serious consequence to the patient. The 
progress of the herpetic clusters, when seated on the 
prepuce, so closely resembles that of chancre, as describ- 
ed by some authors, that it may be doubted whether it 
has not been frequently confounded with the latter.f 

The attention of the patient is attracted to the part by 
an extreme itching, with some sense of heat; and on 
examining the prepuce, he finds one, or sometimes two 
red patches, about the size of a silver penny, upon which 
are clustered five or six minute transparent vesicles, 
which, from their extreme tenuity, appear of the same 
red hue as the base on which they stand. In the course 

* See Huxham, De Aere et Morb. Epid. vol. ii. p. 56.— Plenck, 
Doct. de Morb. Cutan. p. 83. 

t As a similar description of this eruption will be found under 
the article Herpes, in Dr. Rees's New Cyclopedia, I might, 
perhaps, in this, as in some other instances, incur the charge of 
plagiarism, if I did not state that the articles « in Medicine" con- 
tained in that work, from letter C inclusive, were written by my- 
self. 



244 VESICULJE: 

if twenty-four or thirty hours, the vesicles enlarge, antl 
become of a milky hue, having lost their transparency; 
and on the third day, they arc coherent, and assume an 
almost pustular appearance. If the eruption is seated 
within that part of the prepuce, which is in many indivi- 
duals extended over the glans, so that the vesicles are 
kept constantly covered and moist, (like those that occur 
in the throat,) they commonly break about the fourth 
or fifth day, and form a small ulceration upon each 
patch. This discharges a little turbid serum, and has a 
white base, with a slight elevation at the edges; and by 
an inaccurate or inexperienced observer it may be rea- 
dily mistaken for chancre; more especially if any escha- 
rotic has been applied to it, which produces much irrita- 
tion, as well as a deep-seated hardness beneath the sore, 
such as is felt in true chancre. If no irritant be applied, 
the slight ulceration continues till the ninth or tenth day 
nearly unchanged, and then begins to heal; which pro- 
cess is completed by the twelfth, and the scabs fall off 
on the thirteenth or fourteenth day. 

When the patches occur, however, on the exterior 
portion of the prepuce, or where that part does not 
cover the glans, the duration of the eruption is short 
ened, and ulceration does not actually take place. The 
contents of the vesicles begin to dry about the sixth day, 
and soon form a small, hard, acuminated scab, under 
which, if it be not rubbed off, the part is entirely healed 
by the ninth or tenth day, after which the little indented 
*cab is loosened, and falls out. 



HERPES. 24,5 

This circumstance suggests the propriety of avoiding 
not only irritative, but even unctuous or moist applica- 
tions, in the treatment of this variety of Herpes. And 
accordingly it will be found, that, where ulceration oc- 
curs within the prepuce, it will proceed with less irrita- 
tion, and its course will be brought within the period 
above mentioned, if a little clean dry lint alone be in- 
terposed, twice a day, between the prepuce and the 
glans. 

I have not been able to ascertain the causes of this 
eruption on the prepuce. Mr. Pearson is inclined to 
ascribe it to the previous use of mercury.* Whence- 
soever it may originate, it is liable to recur in the same 
individual and often at intervals of six or eight weeks. 

6. Herpes Iris. (Plate LII.) This rare and singular 
morbid appearance, which has not been noticed by me- 
dical writers, occurs in small circular patches, each of 
which is composed of concentric rings, of different co- 
lours. Its usual seat is on the back of the hands, or the 
palms and fingers, sometimes on the instep. Its first ap- 
pearance is like an efflorescence;! but when it is fully 

* Soon after the publication of the 2d edition, my friend,. Mr. 
Copeland, surgeon, of Golden-square, informed me, that he had 
observed this affection of the prepuce to be connected with an ir- 
ritable state, or with actual stricture, of the urethra ; and that by 
the removal of this condition, by means of the bougie, the recur- 
rence of the Herpes had been prevented. 

t Having at first seen it only in its incipient stage, Dr. Willan 



246 TESICULiE: 

formed, not only the central umbo, but the surrounding 
rings become distinctly vesicular. The patches are at 
first small, and gradually attain their full size, which is 
nearly that of a sixpence, in the course of a week, or 
nine days, at the end of which time, the central part is 
prominent and distended, and the vesicular circles are 
also turgid with lymph; and, after remaining nearly sta- 
tionary a couple of days, they gradually decline, and 
entirely disappear in about a week more. The central 
vesicle is of a yellowish white colour; the first ring sur- 
rounding it is of a dark or brownish red; the second is 
nearly of the same colour as the centre; and the third, 
which is narrower than the rest, is of a dark red colour; 
the fourth and outer ring, or areola, does not appear un- 
til the seventh, eighth, or ninth day, and is of a light red 
hue, which is gradually lost in the ordinaiy colour of the 
skin. 

The iris has been observed only in young people, and 
was not connected with any constitutional disorder, nor 
could it be traced to any assignable cause. In one or 
two cases it followed a severe catarrhal affection, ac- 
companied with hoarseness, and also with an eruption 
of Herpes labialis. In others, it had recurred several 
times in the persons affected, occupying always the 
same parts, and going through its course in the same 
periods of time. 

announced the Iris, on the cover of his second part, as a genus of 
•he exanthematic order. 



rupia. 247 

No internal medicine is requisite in the treatment of 
the different species of Herpes, except when the con- 
stitution is disordered, (and then the general antiplo- 
gistic plan must be adopted;) for, like the other eruptive 
diseases, which go through a regular and limited course, 
they cannot be interrupted, or accelerated in their pro- 
gress, by any medicinal expedient; but their termination 
may be retarded by improper treatment. 



IV. RUPIA. 

The eruptive disease, to which this appellation is ap- 
propriated,* was not noticed in the enumeration of the 
genera formerly given by Dr. Willan. For practical 
purposes, it might have been included with the ecthy- 
mata, as it occurs under similar circumstances with the 
ecthyma luridum and cachecticum; but the different 
form of the eruption, for the sake of consistency of lan- 
guage, rendered the separation necessary. 

The Rupia is characterized by an appearance of 
broad and flattish vesicles, in different parts of the body, 
which do not become confluent: they are slightly in- 
flamed at the base, slow in their progress, and succeed- 
ed by an ill-conditioned discharge, which concretes into 

* This term is arbitrarily formed from psres, serdes^ as indica- 
tive of the ill smell and sordid condition of the diseased parts. 



248 VESICUL^l: 

thin and superficial scabs, that are easily rubbed off, and 
presently regenerated.* It appears under some varie- 
ties of form, which may be included under the follow- 
ing heads: 

1. Rupia simplex (Plate LIII.) consists of little vesi- 
cations, containing, on their first appearance, a clear 
lymph, and appearing on many parts of the body. In a 
short time, the fluid included in them begins to thicken, 
and becomes at length opake and somewhat purifmm: 
a slight ulceration of the skin takes place, with a sanious 
discharge, followed by scabbing; and when this heals, 
it leaves the surface of a livid or blackish colour, as if 
from a thickening of the rete mucosum. 

2. Rupia prominens (Plate LIV.) is distinguished by 
elevated, conical scabs, which are gradually formed upon 
the vesicated bases. A fluted scab is first generated, 
and with some rapidity, (e. g. in the course of the night,) 
as the fluid of the vesication concretes. This extends 
itself by the successive small advancement of the red 
border, upon which a new scab arises, raising the con- 
cretion above it, so as ultimately to form a conical crust, 
not unlike the shell of a small limpet. This scab is quite 

* This circumstance serves to mark, the distinction between 
Rupia and ecthyma, independently of the pustular form, and highly 
inflamed hard base, of the latter: for the scab of ecthyma is hard, 
deeply indented, and surrounded by a deep-seated hardness in the 
muscular flesh, especially in the larger forms of it. 



MILIARIA. 



U9 



superficial, and if it be rubbed off, a new incrustation 
covers the excoriated spot in the space of six hours. 
The ulceration, however, is not phagedenic, but at length 
heals; although it often proves very tedious, especially 
in old and intemperate persons, in whom, and in young 
persons of delicate constitution, it most commonly 
occurs. 

These varieties of Rupia are to be combated by the* 
means recommended for the cure of ecthyma; i. e. by 
supporting the system, by means of good, light, nutri- 
tious diet, and by the use of alterative and tonic medi- 
cines; such as Plummer's pill, cinchona, and sarsapa- 
rilla. 

3. Rupia escharotica affects only infants and young 
children, when in a cachectic state, whether induced by 
previous diseases, especially the smallpox, or by imper- 
fect feeding and clothing, &c. whence, among the poor, 
where it is commonly seen, it often terminates fatally. — 
The vesicles generally occur on the loins, thighs, and 
lower extremities, and appear to contain a corrosive 
sanies: many of them terminate with gangrenous eschars, 
which leave deep pits. 



V. MILIARIA. 
An eruption of miliary vesicles (Plate LV. Fig. 1.) 
is perhaps invariably symptomatic, being connected with 
some feverish state of the body, previously induced; 
j i 



250 VESICULiE: 

and it has occurred in every species of fever, continued, 
remittent, inflammatory, and contagious, as well as in 
other cases of disease, in which considerable heat of the 
skin and much sweating had been accidentally excited, 
The physicians and nosologists, who have described a 
miliary fever, as an idiopathic eruptive fever, like the 
measles, smallpox, and scarlatina, have erred in differ- 
ent ways; some of them, in supposing it to originate 
from a specific virus, or acrimony, like the contagion 
of the diseases just mentioned;* and some by actually 
confounding the miliary eruption with the efflorescence 
of scarlatina.f 

* Of the writers who have committed this error, a numerous 
host may be referred to. See Sir Divid Hamilton, De Febre Mi- 
Iiari,1710; — Allionius,De Miliarium Otig. Progressu, Nit. et Cur. 
1758; — Fordyce (Joan.) Hist. Febris Miliaris, 1758; — Collin, 
Epiat. de Pust. Miliar. 1764; — Blackmore on the Plague; — Mac- 
bride, Introduct. to Theor. and Pract. of Med. part ii. chap. 17 ; — 
Baraillon, in Mem. de la Soc. Roy. de MeJ.de Paris, torn. i. p. 193; 
— An Essay on the Cure of the Miliary Fever, by a Subject of Mi- 
thridates, 1751; — Suavages, Nosol. Meth. class, hi. gen. 5 ; — 
Burserius, Inst. Med. vol. ii. p. ii. cap. ii. Sec. See. 

f In the history of the epidemic Miliary fever, which occurred 
at Leipsic, about the year 1650, and which has been considered as 
the prototype of all miliary fevers, this mistake was obviously com- 
mitted. See Godofr. Welsch, Hist. Med. novum islum puerperar. 
morbum continens, qui ipsis tier Friesel dicitur ; in Haller's dis- 
put. Med. torn. v. § 174: — also Christ. Joan. Langius, Prax. Med- 
part. ii. cap. 14. § 9. De Purpura :— .E'muller de Febribus ; — Srha- 
cher, de Febre acut. Exanthem. Lips. 1723, in Haller's Disp. v. 
§ 175; and Saltzmann, Hirst. Pur^uia? Miiiaris alu«e, ibid. § 176. 



MILIARIA. 251 

The Miliaria, of which we here speak, is character- 
ized by a scattered eruption of minute round vesicles, 
about the size of millet seeds,* surrounded by a slight 
inflammation, or rash, and appearing at an uncertain 
period of febrile disorders. The eruption is immedi- 
ately preceded by unusual languor and faintness, by pro- 
fuse perspiration, which often emits a sourish odour, and 
hy a sense of great heat, with a prickling and tingling in 
the skin. It appears most abundantly upon the neck, 
breast, and back, sometimes in irregular patches, and 
sometimes more generally diffused, and remains on those 
parts during several days: on the face and extremities 
it is less copious, and appears and disappears several 
times without any certain order. The vesicles, on their 
first rising, being extremely small and filled with a per- 
fectly transparent lymph, exhibit the red colour of the 
inflamed surface beneath them; but, in the course of 
thirty hours, the lymph often acquires a milky opacity,, 
and the vesicles assume necessarily a white or pearly 
appearance. This seems to have been partly the foun- 
dation of the epithets rubra and alha, w T hich have been 
applied as specific appellations to miliary fevers.f The 

* Whence the denomination of the disease, from milium, the 
millet. 

f I say fiartly, because it appears that, among those physicians 
who confounded the efflorescence of scarlatina with the Miliary 
eruption, the terms of red and white miliary fever, or red and white 
purpura, were used to denote the two eruptions respectively. And 
again, the miliary vesicles, like those of varicella, were occasionally 



252 VESICUL^ 

tongue is furred, and of a dark red colour at the edges, 
and its papillae are considerably elongated; and not unu- 
sually aphthous vesicles and sloughs appear at the same 
time in the mouth and fauces. 

The miliary eruption affords no crisis to the fever, in 
which it supervenes, nor any relief to the symptoms: and 
its total duration, in consequence of a daily rising of 
fresh vesicles, is altogether uncertain; but frequently 
from seven to ten days, and sometimes much longer. 
Indeed, under the former treatment, when the sick lay 
" drowning in sweats," (as Sir Richard Blackmore says 
of one of his patients,) it was not uncommon for these 
" crops ,J of vesicles to be repeated a second, third, or 
even fourth time, and the whole disease to be protracted 
to nearly fifty days.* 

It is scarcely necessary now to enter into any detail of 
proofs, that the miliary eruption is the result of a highly 
heated and perspiring state of the skin; and that, in its 
severe and fatal degree, it is solely the effect of a stimu- 
lating regimen, in a confined atmosphere. The almost 
total annihilation of the disease, of late years, since the 
general adoption of a better practice, is of itself unequi- 
vocal evidence of its origin: while, on the other hand, 

preceded by a diffuse efflorescence,, which disappeared a few days 
after the rising of the vesicles ; whence the red Miliaria has been 
said to be occasionally changed into the white. 

* Blackmore, loc. cit — Brocklesby, in the Med. Obs. and In- 
quir. vol. iv. p 39. 



MILIARIA, ,353 

the rarity of its occurrence, both before the abuse of 
hypothetical speculation had misled physicians from the 
path of observation, and in the practice of those who 
subsequently returned to that path, is an additional cor- 
roboration of the same truth. Hippocrates, whose mode 
of treatment in febrile diseases was not calculated to 
produce excitement, has once or twice but casually men- 
tioned the miliary eruption.* And again, at the latter 
part of the seventeenth century, when, in the practice 
of the majority of physicians, the miliary fever was a 
frequent and fatal occurrence, Sydenham witnessed no 
such fever; but mentions the occasional appearance only 
of miliary vesicles, which he ascribes to their proper 
cause, f More than half a century elapsed, however, be- 
fore the doctrine of Sydenham was established by De 

* See especially the second book of Epidemics, sect. iii. where 
lie states that, in a hot and dry summer, fevers were in some in- 
stances terminated by a critical sweat, and about the seventh, 
eighth, and ninth day, miliary elevations (j^^Kr^xrut xiyxpahoi) 
appeared on the skin, and continued till the crisis. See also the 
hook of Prognostics, where he speaks of miliary sweats {ifyarss 
xzyxpoeihes.) 

t Sir Richard Blackmote states, that miliary fever was " the 
most frequent in this country of all the malignant kind ;" and that, 
when the eruption was copious, it was "often fatal and always 
dangerous." (loc. cit.) His contemporary, Sydenham, said of 
the miliary eruptions, " Licet sua sponte nonnunquam ingruant, 
saepius tamen lecli calore et cardiacis extorqucntur." See his 
Sched. de Nov. Febris Ineressu. 



254 VESICUL^: 

Haen, in Germany, and by Mr. White, of Manchester, 
Dr. Cullen, and others, in this country.* 

Among the various circumstances under which the 
miliaria was formerly excited, the puerperal state ap- 
pears to have been most frequently the source of it; in- 
somuch that it was first described as an epidemic among 
puerperal women. This is sufficiently accounted for by 
the treatment, which was unhappily pursued during the 
confinement after child-birth, and of which an impres- 
sive description is given by Mr. White. For not only 
was the mother immediately loaded with bed-clothes, 
from which she was not allowed to put out " even her 
nose," and supplied with heating liquors from the spout 
of a tea-pot: but to her room, heated by a crowd of vi- 
sitors and a fire, all access of air was denied, even 
through a key-hole. From these causes, fever was al- 

* See Dc Haen. Theses sistent. Febrium Divis. § 4 ; and again 
in his Rat. Medend. vo\. ii. p. 8 — White, on the Management of 
pregnant and lying-in Women, chap. ii. — Cullen. First Lines, par. 
723, and Nosol. Method. It appears, however, that, in the mid- 
dle of the last century, the better educated members of the pro- 
fession had already adopted the right opinions upon the subject. 
For a weak anonymous writer, of the Blackmore school, in 1751, 
in reprehending what he calls the " stupidity" and " unpardonable 
ignorance" of his brethren respecting the disease, ascribes it to 
"the prevailing opinion of some physicians, that this fever is a 
creature of our ovjn making" which, he believes, had " run through 
the whole college, and from thence the dangerous infection been 
conveyed to the apothecaries, &c." See the Essay by a Subject 
of Mithridates, Pref. p. iv. 



MILIARIA. 255 

most necessarily induced, with the most profuse sweats, 
oppression, anxiety, and fainting; and these again were 
aggravated by spicy caudles, spirits, opiates, and ammo- 
niacal medicines. That numbers should perish, under 
such management, with every symptom of malignity, and 
that many 'who survived it, should escape with broken 
constitutions, will surprise no person who is acquainted 
with the baneful influence of over excitement in febrile 
complaints.* 

With other fevers, in which a similar method of treat- 
ment was pursued, though in a less degree, and which 
confined the patient to bed, the miliary eruption, with 
its attendant languor and exhaustion, was frequently 
conjoined, especially with catarrhal and rJieumatic fe- 
vers, and also with typhoid, remittent, and intermittent 
fevers. Whence the writers, who have described the 

* The occurrence of this fatal Miliaria must be deemed one of 
the greatest ofifirobria medicorum; for it was the direct result of a 
mischievous practice, originating in a false hypothesis, respecting 
the concoction and expulsion of morbid matter: and when we re- 
collect, that there was not a febrile disease in which this mischief 
was not more or less inflicted on the sick, we must blush for the 
character of our art. " Quid verd demum generi humano calami- 
tosius," exclaims de Haen, " quam quod, et plebe et medicis con- 
spirantibus, tot milleni quotannis aegri, ab ipso principio acutorunij, 
in sudores symptomaticos agitentur, ac veluti fundantur, ut coacta 
omnino crisis, in plerisque aut lethalis aut periculosa saltern, pro- 
ducatur; interea dum salutaria naturae molimina turbantur, con- 
funduntur, ac penitus sufflaminantur. Faxit Deus, ut demum sa- 
piant Phryges !" — De Febrium Divis. 



256 VESICUL.fi: 

miliary fever, speak of it as being disguised under, or 
counterfeiting the character of these fevers respectively. 
In the summer, indeed, where ventilation and coolness 
are not sufficiently attained or attended to, a slight mi- 
liary eruption is even now occasionally seen: and a Mi- 
liaria clinica, in fact, may be thus induced by any cir- 
cumstance that confines a person to bed; as an acci- 
dent or a surgical operation,* an attack of hysteria, 
a state of asthenia, &c. From the increase of cutaneous 
heat, connected with the exanthematous fevers of the 
nosologists, some degree of Miliaria is liable to occur in 
them all, but more especially in scarlatina; and a few 
larger pearl-coloured vesicles also occasionally appear.f 
It is unnecessary to dwell upon the method of treat- 
ment applicable to Miliaria; since, under the full em- 
ployment of ventilation, and a cool regimen, the symp- 
tom will very rarely be produced. The room, in which 
a puerperal woman, or a patient under any febrile dis- 
ease, is confined, ought to be as free from all unpleasant 
odour as any other apartment; and under the cordial 
influence of pure air, the support of spirituous and 
vinous liquors is so far from being requisite, that a 
small proportion of these stimulants will produce even 
a deleterious excitement. J Extreme cleanliness, a fre- 

* Mr. White, Ioc. cit. 

t See Fordyce (loc. cit.) " Nonnunquam bullae insignes, apice 
digitinon minores, hie elevantur." — Also the Anon. Essay on the 
Cure of Mil. Fever; — and Brocklesby, loc. cit. 

\ Mr. White obseves, that a woman in child-bed is so much ex- 






ECZEMA. 251 

quent change of linen, cool diluent drinks, light diet, 
and the other circumstances of what has been called 
the antiphlogistic regimen, will always be attended to 
with advantage, where the miliary eruption shows it- 
self. The mineral acids, if no other symptom contra- 
indicate the use of them, are advantageous. 



VI. ECZEMA. 

The Eczema* is characterized by an eruption of 
small vesicles, on various parts of the skin, usually set 
close or crowded together, with little or no inflammation 
round their bases, and unattended by fever* It is not 
contagious. 

hausted by the mode of treatment before described, " that the high- 
est cordials have been necessary to support her : nay, I have been 
credibly informed," he adds, " that under these circumstances a 
patient has sometimes drank a gallon of wine in a single day, ex- 
elusive of brandy, and of the cordials from the apothecary's shop., 
and all this too without intoxication." Loc. cit. chap, viii.— Similar 
enormous potations of wine have been recommended by later 
practitioners in typhoid fevers, who have not been aware, that the 
very impunity, with which these doses have been administered, 
has arisen from the artificial exhaustion of the patient by external 
circumstances, and not from the necessary tendency of the dis- 
ease. Many facts have occurred to my notice, in the course of 
my attendance at the Fever Institution, which have satisfied me of 
the correctness of this opinion, which I may probably illustrate at 
a future opportunity. 

* Aetius observes, that an eruption of hot and smarting phlyc- 

Kk 



258 VESICUL^l: 

This eruption is generally the effect of irritation, 
whether internally or externally applied, and is occa- 
sionally produced by a great variety of irritants, in per- 
sons whose skin is constitutionally very irritable. It 
differs from miliaria, inasmuch as it is not the result of 
fever, and, unless it be very extensively diffused, is not 
accompanied with any derangement of the constitution: 
even in the most violent cases, the functions of the 
sensorium and of the stomach are seldom disturbed. 
When limited to the fingers, hand, and part of the fore- 
arm, it is not unfrequently mistaken for scabies: but it 
may be distinguished by the appearance of its acumi- 
nated and pellucid vesicles; by the closeness and uni- 
formity of their distribution; by the absence of sur- 
rounding inflammation, and of subsequent ulceration; 
and, in many cases, by the sensations of smarting and 
tingling, rather than of itching, which accompany them. 
According to the nature of the irritating cause, the ex- 
tent and form of the disease are somewhat various. One 
of the most common species is the 

1. Eczema solare, (Plate LVI.) which occurs in the 

taenae arises in all parts of the body, without proceeding to ulcera- 
tion. " Eas iy.fyp.tx.rx, ab ebulliente fervor e, Graeci vulgo appel- 
lant." Tetrab. iv. serm. i. cap. 128. According to Paulus (lib. iv. 
cap. 10,) and Actuarius (lib. vi. cap. 8,) they were also called 
iregtfyftetTx, and Trepifyc-^ctrct, " quasi vchementer ferventia." See 
Gorrseus, Defin. Med. ; and Senncrt. Pract. Med. lib. v. part i. 
cap. 2. 



ECZEMA. 259 

summer season, and is the effect of irritation from the di- 
rect rays of the sun, or from the heated air. Hence it 
affects almost exclusively those parts of the surface 
which are exposed to their influence; as the face, the 
neck, and fore-arms, in women, but more particularly 
the back of the hands and fingers. The eruption is pre- 
ceded and accompanied by a sense of heat and tingling, 
and these sensations are aggravated even to smarting, 
when the parts affected are exposed to the sunshine, or 
to the heat of a fire. The whole fingers are sometimes 
swelled,* and so thickly beset with the vesicles, as to 
leave no interstice of the natural appearance of the skin, 
nor any intervening redness. The vesicles themselves 
are small, and slightly elevated; they are filled with a 
thin, milky serum, which gives them a whitish colour, 
or sometimes with a brownish lymph; and they are with- 
out any surrounding inflammation. On the upper part 
of the arm, however, and, in women, on the breast, 
neck, and shoulders, the eczematous vesicles are some- 
times surrounded by an inflammatory circle; when they 
are popularly termed heat-spots. It sometimes happens, 
indeed, in men of sanguine temperament, who use vio- 
lent exercise in hot weather, that these vesicles are in- 
termixed, in various places, with actual phlyzacious 

* As this eruption about the fingers, the ball of the thumbs, and 
the wrists, is often continued for several weeks, it is in this situa- 
tion more particularly liable to be mistaken for the itch : but the 
circumstances just noticed, as well as those mentioned under the 
head of scabies (page 200) will contribute to aid the diagnosis. 



260 VEMCtJLM: 

pustules, or with hard and painful tubercles, which ap- 
pear in succession, and rise to the size of small boils.. 
and suppurate very slowly. This, however, is a more 
frequent occurrence in the more local forms of the dis- 
ease, included under the second head. 

The eruption is successive, and has no regular period 
of duration or decline: it commonly continues for two 
or three weeks, without any particular internal disorder. 
The included lymph becomes more milky, and is gra- 
dually absorbed, or dried into brownish scales, which 
exfoliate, or into brownish yellow scabs, of the size ol 
a small pin's head, especially when the vesicles are 
broken. But successive eruptions of the vesicles are 
apt to appear, which terminate in a similar manner by 
exfoliation or scabbing; and in those persons who, by 
the peculiar irritability of their skin, are much predis- 
posed to the disorder, it is thus continued many weeks, 
to the end of autumn, or even prolonged to the winter. 
When this happens the vesicles generally pour out an 
acrid serum, by which the surface is inflamed, rendered 
tender, and even slightly ulcerated, and the disease as- 
sumes the form of impetigo. 

The course of this disorder does not appear to be ma- 
terially shortened by the operation of medicine. The 
mineral acids, with a decoction of cinchona, or other 
vegetable tonic, and a light but nutritious diet, seem to 
be most effectual in diminishing the eruption. When it 
has occurred after long continued travelling, or any 
other severe fatigue, and appears to be accompanied with 



ECZEMA. 261 

some degree of exhaustion of the powers of the consti- 
tution, a course of serpentaria, or sarsaparilla, is exceed- 
ingly beneficial. Active and repeated purgation is ad- 
verse to the complaint. Simple ablution with tepid 
water, contributes to relieve the smarting and tingling of 
the parts affected, which do not bear unguents, or any- 
stimulant application. 

2. Eczema impetiginodes. (Plate LV. Fig. 2.) A. 
local Eczema is produced by the irritation of various 
substances; and, when these are habitually applied, it is 
constantly kept up in a chronic form, differing from the 
impetigo only in the absence of pustules. Small separate 
vesicles, containing a transparent fluid, and, like the psy- 
dracious pustules, imbedded in the skin, or but slightly 
elevated, arise, and slowly increase: they are attended 
with pain, heat, smarting, and often with intense itching, 
When they break, the acrid lymph, that is discharged, 
irritates and inflames the surrounding cuticle, which be- 
comes thickened, rough, reddish, and cracked, as in 
the impetiginous state. The alliance, indeed, of this 
affection with impetigo is further proved by the circum- 
stance, that, in some cases, vesicles and pustules are in- 
termixed with each other; and, in different individuals^ 
the same irritant will excite a pustular or a vesicular 
eruption respectively; the vesicular disease being always 
the most painful and obstinate. Of this we have an ex- 
ample in the affection of the hands and fingers, produced 
by the irritation of sugar, which is commonly called the 



262 VESICfflLE: 

grocers itch; and which is in some persons vesicular, in 
others pustular. The acrid stimulus of lime occasions 
similar eruptions on the hands of bricklayers: and one 
of the most severe cases that I ever witnessed, occurred 
on the hands of a Jilemaker, being occasioned perhaps 
by the united irritation of the heat of the forge and the 
impalpable powder of steel with which they were con- 
stantly covered during his work. In like manner both 
vesicular and pustular affections are excited by the local 
irritation of blisters, stimulating plasters, and cataplasms 
of mercury, tartarized antimony, the oil of the cashew 
nut, the Indian varnish, arsenic, valerian root, &c* 
These often extend to a considerable distance beyond 
the part to which the irritants were immediately applied, 
and continue for some time, in a successive series, after 
the stimulus has been withdrawn, especially in irritable 
and cachectic habits. Thus, when a blister is applied to 
the pit of the stomach, an eruption of vesicles, inter- 
mixed often with ecthymatous pustules, and inflamed 
tubercles and boils, extends, in some cases, over nearly 
the whole abdomen, or to the top of the sternum; or, if 
the blister be applied between the shoulders, the whole 
of the back and loins becomes covered with a similar 
eruption. These tubercles and boils suppurate very 
slowly and deeply in some habits, and are ultimately filled 
with dry dark scabs, which do not soon fall off; and when 
the sores are numerous, they produce some degree of 

*See impetigo, above, p. 154. 



ECZEMA. 263 

feverishness, and much pain on motion. In other re- 
spects/ the constitution suffers no injury from this 
tedious eruption; although from its duration, which is 
sometimes extended to two or three weeks, it occasions 
more inconvenience than the original applications. 

The first step towards the cure of these varieties of 
Eczema is, to remove the irritating cause, where that is 
obvious. The eruption, however, is not easily removed: 
but the painful sensations connected with it are greatly 
alleviated by simple poultices, and by frequently washing 
the parts with warm gruel, and milk or bran and water. 
Where there is any other evidence of a cachectic condi- 
tion of the patient, similar treatment must be prescribed 
for the improvement of the general health, as is recom- 
mended in ecthyma.* 

3. Eczema rubrum.j (Plate LVII.) The most re- 
markable variety of the Eczema rubrum, is that which 

* The irritation produced by the attrition of the tight parts of 
our dress, as about the knees, neck, &c. which commonly produces 
a mere intertrigo (see p. 124,) occasions, in some persons, an ec- 
zematous eruption. Sauvages has hence made two species of 
herpes, excited by the garter and the bandages of the neck, which 
he calls herpes fieriscelis and h. collaris. 

t There is perhaps a little incongruity in this species of Eczema, 
when the generic character is considered ; but in every respect, 
except the surrounding redness, it accords with the genus, differing 
equally from the mere rash of the erythemata, and from the symp- 
tomatic and febrile miliaria. 



264, VESICULiE: 

arises from the irritation of mercury.* (Plate LVIII.) 
But the disease is not exclusively occasioned by this 
mineral, either in its general or more partial attacks: it 
has been observed to follow exposure to cold, and to 
recur in the same individual, at irregular intervals, some- 
times without any obvious or adequate cause.f 

The Eczema rubrum is preceded by a sense of stiff- 
ness, burning heat, and itching, in the part where it 
commences, which is most frequently the upper and in- 
ner surface of the thighs, and about the scrotum in men: 
but sometimes it appears first in the groins, axillas, or 
in the bend of the arms, or about the wrists and hands, 
or in the neck. These sensations are soon followed by 
an appearance of redness, and the surface is somewhat 

* Whence the disease has been called eczema mercuriale (see 
Mr. Pearson's " Obs. on the Effects of var. Articles of the Mat. 
Med. in Lues Ven." chap. xiii. 2d edit.) — erythema mercuriale 
(see Dr. Spens. and Dr M'Mullins in the Edin. Med. and Surg. 
Journ. vol. i. and ii.) — hydrargyria (see Dr. Alley's " Obs. on 
the Hydrargyria, or that vesicular Disease arising from the Exhi- 
bition of Mercury," Lond. 1810.) — and mercurial lepra (see a 
Tract of Dr. Moriarty of Dublin.) 

f See a description of two cases by Dr. Rutter (Edin. Med. and 
Surg. Journal, vol. v. p. 143 ) and Dr. Marcet (Medico-Chirurgi- 
cal Trans, vol. ii. art. ix.) under the appellation of erythema, 
which occurred several times in both patients to a severe degree. 
It is worthy of remark, however, that, in both these instances, the 
first attack of the disease occurred after a gonorrhoea, for which, 
in the one, some mercury had certainly, and in the other had pro- 
bably, been administered. 



ECZEMA. 2&5 

rough to the touch. This, however, is not a simple ery- 
thema: for on examining it minutely between the light 
and the eye, or with a convex glass, the roughness is 
found to be occasioned by innumerable minute and pel- 
lucid vesicles which have been mistaken for papulae. In 
two or three days, these vesicles, if they are not ruptured, 
attain the size of a pin's head; and, the included serum 
then becoming somewhat opake and milky, the charac- 
ter of the eruption is obvious. It soon extends itself 
over the body and limbs in successive large patches, and 
is accompanied by a considerable swelling of the inte- 
guments, such as is seen in smallpox and other eruptive 
fevers, and by great tenderness of the skin, and much 
itching. When the vesicles begin to lose their transpa- 
rency, they generally burst, and discharge, from nume- 
rous points, a thin acrid fluid, which seems to irritate the 
surface over which it passes, and leaves it in a painful, 
inflamed, and excoriated condition. The quantity of 
this ichorous discharge is very considerable, and it gra- 
dually becomes thicker and more adhesive, stiffening the 
linen which absorbs it, and which thus becomes a new 
source of irritation: it emits also a very fetid odour. 
This process takes place in the successive patches of 
the eruption, until the whole surface of the body, from 
head to foot, is sometimes in a state of painful excoria- 
tion, with deep fissures in the bends of the joints, and in 
the folds of the skin of the trunk; and with partial scaly 
incrustations, of a yellowish hue, produced by the dry- 
ing of the humour, by which also the irritation is aug- 
l1 



266 VESICUL^: 

mented. The extreme pain arising from the pressure 
of the weight of the body upon an extensive portion of 
such a raw surface, is sufficient to give rise to an accele- 
ration of the pulse, and white tongue; but the functions 
of the stomach and of the sensorium commune are not 
evidently disturbed by this disease. 

The duration of this excoriation and discharge is un- 
certain and irregular: when only a small part of the 
body is affected, it may terminate in ten days; but when 
the disorder has been universal, the patient seldom com- 
pletely recovers in less than six weeks, and is often af- 
flicted to the end of eight or ten weeks. By so severe 
an inflammation the whole epidermis is destroyed in its 
organization; and when the discharge ceases, it lies 
loose, assuming a pale brown colour, which changes al- 
most to black before it falls off in large flakes. As in 
other superficial inflammations, however, the new red 
cuticle that is left is liable to desquamate again, even to 
the third or fourth time, but in smaller branny scales, 
of a white colour; and a roughness sometimes remains 
for a considerable period, like a slight degree of psoria- 
sis. In some instances, not only the cuticle, but the 
hair and nails are also observed to fall off; and the lat- 
ter, when renewed, are incurvated, thickened, and fur- 
rowed, as in lepra. 

The Eczema rubrum, however, even from the irrita- 
tion of mercury, is often limited to a small space; and 
then the discharge is slight, and its whole duration short. 
Similar local attacks of it occur in irritable constitutions. 



ECZEMA. 267 

especially in hot weather, affecting the hands and wrists, 
the neck and external ear, and other parts, but without 
any constitutional disorder. Successive crops of the ve- 
sicles arise, in irregular patches, with a red blush around 
them, which produce partial incrustations, as the ichor, 
that issues, is dried: and by these vesications and desic* 
cations of the matter the affection is kept up for some 
weeks. 

The treatment of this species of Eczema may be 
comprised in few words; for it is principally palliative. 
But although medicine may not possess the power of 
shortening the period of its duration ; yet the omission of 
the palliative measures will allow an extreme aggrava- 
tion of the sufferings of the patient to take place, and 
probably prolong it beyond its natural course, as well as 
contribute to wear out the vigour of his constitution. 

The misery and exhaustion, resulting from the exces- 
sively tender and irritated state of the skin, may be great- 
ly alleviated by frequent ablution or fomentation with 
warm gruel, or strained bran and water; or by the fre- 
quent use of the warm bath, which has the advantage of 
cleansing the surface, without occasioning any abrasion 
by friction. A constant application of poultices has 
produced considerable ease to the patient, when the af- 
fection was confined to the extremities. Where the cu- 
ticle has exfoliated, Mr. Pearson recommends the appli- 
cation of a mild cerate, consisting of litharge plaster, 
wax, and oil,* spread thickly on linen rollers, and re- 

* See above, page 12, note. 



268 VES1CULM: 

newed twice a day. Witii4he same view of diminishing 
the irritation of the surface, the bed and body linen of 
the patient, which becomes hard and stiff as the dis- 
charge dries upon it, should be frequently changed. 

Every additional irritation from stimulating food and 
drink should be avoided; the bowels should be kept 
open by the administration of occasional laxatives; and 
some saline diaphoretic, or an antimonial, should be 
given regularly, to which an opiate may be added, for 
the purpose of soothing the sensations of the patient 
The sulphuric acid is grateful and refreshing; and, in 
the decline of the swelling and discharge, it may be 
combined advantageously with the liberal exhibition of 
cinchona and sarsaparilla. 



VII. APHTHA. 
THRUSH. 

The Aphtha? are small, whitish, or pearl-coloured ve- 
sicles,* appearing on the tongue, the lips, and the inte- 

* The vesicular character of the aphthous eruption has been 
pointed out by several accurate observers ; especially by Van 
Swieten, in commenting upon the word ulcuscula used by Boer- 
haave, aph. 978 ; by Sauvages, who considers their character as 
fihlyctanous ; and by Prof. Arnemann, who describes them as 
small elevations, of a greyish white colour, "serosa quodam liguore 
l'eferti." (Comment, de Aphthis, § ii.) See also Welti, Diss, de 
Exanthem. Fonte Abdominali, § vi.; Callisen, Syst. Chir. Hod. § 
834 ; and Plenck, Doctr. de Morb. Cutan. class, x. who still more 



APHTHA. 269 

rior surface of the mouth and throat, generally in con- 
siderable numbers, proceeding to superficial ulceration, 
and terminating by an exfoliation of whitish crusts." 

This affection of the mouth, which has been described 
by medical writers from Hippocrates downwards, has 
been almost universally noticed as a frequent occurrence 
during the period of infancy,* and generally ascribed 
to disorder of the first passages, or considered as the 
result of gastric and eruptive fevers. In truth, it occurs 
in connection with various states of disease, both acute 
and chronic, and at all ages, where great debility is in- 
duced; but for practical convenience, it may be treated 
of under the following heads. 

1. Aphtha lactantium.^ Aphthous eruptions are 
most frequently seen in infants, in whom they some™ 

distinctly describes them. " Incifiiunt Aphthae sub forma vesicu- 
larum miliarium albarum, quae in apice foraminulum gerunt, dein 
collabuntur et aliquantum latescunt." — Some English writers 
have called them " little white specks" (see Underwood, vol. i. 
p. 62.) " little white specks or sloughs," (Armstrong on the Man. 
of Children, p. 18.) or merely " a white fur," (Syer, on Man. of 
Infants, p. ii. chap. 3.) having attended only to the ultimate state 
of the eruption. 

* Hippoc. aph. 24. sec. iii. Sec— -Celsus, lib. ii. cap. 9. and lib. 
viii. cap. 42. — Aetius, tetr. ii. serm. iv. cap. 39. — Julius Pollux, 
Onomast. lib. iv. cap. 24. 

t The Aphthae infantiles of Plenck, spec. 1. See also Sauvages, 
cl. iii. gen. x. Aphtha lactucimen, spec. 1. The appellation of 
lactumina or lactucimina, was given to the infantile Aphthae by 



270 FESIGtnUE: 

times appear without any considerable indisposition ; but 
they are often accompanied by restlessness and slight 
febrile symptoms, especially when the stomach and bow- 
els are much deranged. The nurse is led to suspect 
their occurrence by the difficulty and apparent pain with 
which the infant sucks, and by the heat of its mouth, as 
perceived by the nipple, which at length becomes in- 
flamed and even excoriated. The Aphthae appear first 
on the edges of the tongue, or at the angles and inside 
of the lips, and often extend over the whole surface of 
the tongue, palate, inside of the cheeks, and into the 
fauces; the surface on which they arise is of a red or 
purplish hue: the tongue is sometimes slightly tumid, 
and its papilla?, especially near the extremity, are elon- 
gated and inflamed, protruding their red tips above the 
rest of the surface, nearly as in scarlet fever. The 
aphthous vesicles are of a white colour, and semi-opake, 
and speedily put on the appearance of minute fragments 
of curd, adhering to the surfaces just mentioned. At 
various periods, from twelve hours to several days, these 
specks become loose and fall off, leaving the surface 
smooth and red. Others, however, commonly spring 
up, and go through a similar course, while at the same 
time new ones appear on other parts; so that at length 
the whole surface of the tongue and mouth is often 
covered with a sort of whitish granulated crust, formed 

Amatus Lusitanus (Curat. Medic, cent, v.,) upon the supposition 
that they originated from a vitiated condition of the milk. 



APHTHA. I 211 

of the coherent Aphthae. Sometimes these crops are 
renewed several successive times; and not unfrequently 
the removal and repullulation are only partial, and the 
general crust remains for several weeks. The Aphthae 
appear to extend down the oesophagus, and are supposed 
to affect the internal surface of the stomach, and of the 
whole intestinal canal, when tenesmus ensues, with a 
redness and partial excoriation about the anus: these 
latter symptoms, however, may be occasioned by the 
irritation of the morbid excretions from the bowels, 
which are usually discharged under the occurrence of 
severe aphthous eruptions. The trachea is occasionally 
affected with the Aphthae; but they very rarely extend 
to the cavity of the nose.* 

The Aphthae of infants are most commonly the result 
of disorder in the stomach and bowels, combined with 
debility. Hence they occur in sucking infants, where 
the supply of milk afforded by the nurse is inadequate, 
or imperfect in its qualities; but still more frequently 
and severely, where a child is brought up, without being 
suckled, upon unnatural or improper food. In either 
case, the tendency to Aphthae is increased by whatever 
contributes to impair the general health; as want of 
cleanliness, confined air, neglect of giving exercise, al- 
lowing the child to sleep too much under the bed- 
clothes, &c. Indigestion and its consequences, especially 
acidity, are occasioned by giving the food too thick, too 

* Callisen, loc. cit. 



212 VESICULiE: 

hot, or too sweet, or in any other way widely different 
from that which the provision of nature suggests. 

The Aphtha? of infants, when accompanied with slight 
general indisposition, or only with acidity at the stomach, 
and especially when they are few and scattered, are not 
indicative of danger, nor productive of much inconve- 
nience. But when they are very copious, coalescing 
into an extensive coating over the tongue, mouth, and 
throat, or are accompanied with an obstinate and irri- 
tating diarrhoea, fever, and restlessness, — or when they 
supervene on the state of debility and emaciation, which 
is left by measles, erysipelas, and other acute diseases, 
or on a chronic marasmus, — they not only betoken a 
dangerous state of constitutional distress, but contribute, 
by the inability of taking nourishment which they occa- 
sion, to augment that state. They are also unfavoura- 
ble when they assume a dark hue. 

In the milder degrees of Aphtha lactantium just men- 
tioned, slight remedies are sufficient to alleviate or re- 
move the disease. The acidity in the first passages is 
often readily corrected by some testaceous powder, 
which, if the bowels be not irritable, may be joined with 
a little rhubarb or magnesia; or by the pulvis contra- 
yervae comp. if they are in the opposite state, and the 
child weakly. At the same time, the nutriment of the 
patient should be regulated, by attending to the diet and 
general health of the nurse; or, if the child be not 
suckled, by procuring a wet nurse, where that is prac- 
ticable, which often speedily cures the complaint. 



APHTHA. 273 

Various local applications have been employed for the 
removal of Aphthae from the earliest times, of a gently 
-astringent nature; and when they are not made too 
stimulant, especially in the commencement of the erup- 
tion, they not only serve the good purpose of coagulating 
and removing the mucous and clammy discharge, but 
also diminish the tendency to re-sprout in the aphthous 
surfaces. The most effectual detergent of this kind is 
the borax, recommended by Mr. Gooch, of Norwich,* 
and now in the hands of every nurse. It is convenient- 
ly combined with water, mucilage, syrup, or honey, in 
the proportion of one-twelfth, or even one-eighth part of 
the salt. It is unnecessary to describe the compositions 
of honey of roses, syrup of mulberries, &c. with small 
proportions of muriatic or sulphuric acid, or of the sul- 
phate of zinc, or of some absorbent powder, which dif- 
ferent practitioners have preferred. Where the surface 
is exceedingly tender and excoriated, some mild and lu- 
bricating application, such as the compound of cream, 
with the yolk of eggs and syrup of poppies, recommend- 
ed by Van Swieten,f should be first employed, and the 
restringents gradually introduced, as the irritability is di- 
minished. 

At a later period of infancy, the Aphthae partake more 
of the nature of those which appear in adults: they sel- 
dom occur, except as symptomatic of some more serious 
derangement of the organs of nutrition, or as the seque- 

* See his Surg, Observations. f Comment, ad Aph. 99Q, 
Jh m 



2U VESlCULiE: 

la) of febrile disease; and are consequently indicative of 
great danger, and more difficult of cure. If the child 
have been long at the breast, it is probable that the milk 
has become deteriorated in quality, or insufficient in 
quantity; and weaning, or a change of nurse may be ne- 
cessary. If a state of marasmus, with emaciation, tu- 
mid abdomen, and morbid excretions from the bowels, 
have supervened, the usual course of absorbents and al- 
teratives, the hydrargyria cum creta, or the grey oxide 
with soda and testaceous powder, must be carefully ad- 
ministered, and followed by mild tonics. Where the 
Aphtha? assumes a brown hue, or appear in the state ol 
debility consequent on acute diseases, the general strength 
must be supported by light tonics and cordials, with pro- 
per diet; such as a weak decoction of cinchona or cas- 
carilla, or the solution of the tartrite of iron, with rhu- 
barb, light animal broths, and preparations of milk with 
the vegetable starches. 

2. Aphtha adultorum. In children grown up, and 
in adult persons, Aphtha? occur under a great variety of 
circumstances, being symptomatic of numerous diseases 
both acute and chronic. They not only occur after 
smallpox, measles, erysipelas, and scarlet fever; but sel- 
dom fail to appear, whenever the constitution has been 
weakened by old age, by long confinement from wounds 
and accidents, from dropsical, gouty, and dyspeptic com- 
plaints, from diarrhoea, chlorosis, consumption, and hec- 



APHTHA. 215 

tic fever of every kind;* in the latter diseases, indeed, 
the Aphthae are usually indications of the approach of 
dissolution. The peculiar tendency of autumnal fevers, 
in cold and damp seasons, to produce Apthae, especially 
when combined with affections of the bowels, or occur- 
ring in puerperal women, has been noticed by many 
writers; as well as the connection between the aphthous 
and miliary eruptions under a heating regimen.f The 
Aphthae, like the miliaria, when they supervene in these 
fevers, never produce any amendment of the symptoms, 
as the continental writers have stated, but rather seem 
to aggravate them, and to prolong their duration. 
They, always, indeed, imply a dangerous state of the 
system, when they accompany other diseases; and espe- 
cially when they appear first in the pharnyx, and ascend 
from the stomach; when there is much anxiety, pain, 
and heat of the praecordia, with sickness and hiccup; 
and when they are among the sequelae of fevers, the 
pulse at the same time remaining small and frequent, 
and the appetite failing to return. 

* See Callisen, loc. cit — « Neque infrequenter (Apthse) in 
adultis metastasi imperfectse, infidse, in febribus continuis, exan- 
thematicis, putridis, inflammatoriis, ientis, a bUppuratione interna 
seupure resorpto, vel alvifluxu, vires pessundanti inductae, deben- 
tur." — See also Willan, Reports on Dis. of London, p. 114, and 
Arnemann, loc. cit. § iii. de Aohthis adultorum. 

f See Arnemann and Willan, ibid — Van Swieten ad Apn. 983. 
Sydenham, sect. iv. cap. 3 — Stoll, Rat. Med. torn. ii. p. 167, Hux- 
ham, de Aere et Morb. Epidem. lib. ii. p. 29. — Frank, de curand. 
Horn. Morbisj lib. iii. § 366. 



276 VESICUL.E 

The principal objects of medicine, in these cases, are 
to restore the energy of the constitution, and to relieve 
the local complaint. The former indication is to be 
fulfilled by means of cinchona and the mineral acids, 
where the bowels will admit of them, by light but nutri- 
tious diet, and by the exercise of gestation, when it can 
be obtained. For the latter, frequent ablution of the 
mouth and throat with cold water, and the use of the va- 
rious linctuses and lotions, before enumerated, must be 
resorted to. 

3. Aphtha anginosa. This appellation may be given 
to a species of sore throat, which is not unfrequently ob- 
served during damp and cold autumnal seasons, espe- 
cially in women and children. It is preceded by slight 
febrile symptoms, which seldom continue many days: on 
the second or third day, a roughness and soreness are 
perceived in the throat, which, on inspection, is found to 
be tumid, especially the tonsils, uvula, and lower part of 
the velum pendulum, and considerably inflamed, but of 
a purplish red colour. The same colour extends along 
the sides of the tongue, which is covered in the middle 
with a thin white crust, through which the elongated 
and inflamed papillae protrude their red points. Small 
whitish * specks form on these parts, which usually re- 
main distinct, and heal in a few days, but occasionally 
coalesce, and produce patches of superficial ulceration. 
The complaint is sometimes continued three weeks, or 



APHTHA. 277 

a month, by successive appearances of the Aphthae, but 
without any constitutional disturbance. 

This disease appears to arise from the influence of 
cold and moisture, unwholesome diet, and acrid effluvia 
taken into the lungs. In the latter mode, it is produced 
in persons who attend on patients affected with confluent 
smallpox, scarlatina, anginosa, or other malignant fevers. 
Although there is no clear evidence of its propagation 
by contagion, it is frequently seen to attack several chil- 
dren in the same family about the same time, or in very 
quick succession. 

There appears to be no danger in this affection, and 
medicine does not materially abbreviate its duration. 
A light diet, with diluent drinks, and gentle laxatives, 
where there is a disposition to inactivity in the bowels, 
constitute the only treatment required for its cure. 
Leeches and blisters seem to be rather detrimental than 
advantageous; and cinchona, with mineral acids, to be 
useless, until the decline of the disorder, when they 
contribute to restore the strength.* 

* See Dr. Willan's Reports on Dis. in London, p. 1 1 1 ; — and my 
Reports of the Public Dispensary, Edin. Med. and Surg. Journal, 
for January 1813. 



278 



Ordw VII 

TUBERCULA. 

The Order of Tubercles (Def. 7.) comprehends eight 
genera: but as some of them require only surgical treat- 
ment, some are of rare occurrence, and some are un- 
known in this country, they will not require a very ample 
discussion in this place. 



I. PHY MA. 

Under the genus, Phyma,* Dr. Willan intended to 
comprise the terminthus, the epinyctis, the lesser spe- 
cies of boil (furunculus,) and the carbuncle of authors. 
These tubercular affections are commonly treated of in 
chirurgical works, and I have nothing to add to the 
general information on the subject. 

* According to Paulus, the term pvpct was employed to signify 
in general a suppurating tumour, but in particular a suppurating 
tumour in a glandular part. (De Re Med. lib. iv. cap. 22. See also 
Oribas. de Morb. Cur. lib. iii. c. 34; and Actuar. Meth. Med. lib. ii. 
cap. 12.) Hippocrates uses the term in the general sense (aph. 
20, § iii. and aph. 82, § iv.) and speaks also of scrofulous phymata, 
Qvfutrx xotpa&x, in Praedict. lib. ii. § ii. 77. Foes. See also Celsus, 
lib. v. cap. 18. 



MOLLUSCUM. 219 

II. VERRUCA. 
The same considerations induce me to omit all detail 
relative to the varieties of Verruca, which is here 
understood in its ordinary sense, denoting the cuticular 
excrescences, called ivarts. 



III. MOLLUSCUM. 

This form of tubercular disease (Plate LX. Fig. 1.) 
is noticed rather as a singularity, which occasionally oc- 
curs, and of which a few instances are recorded, than 
as an object of medical treatment. It is characterized 
by the appearance of numerous tubercles, of slow growth 
and little sensibility, and of various sizes, from that of 
a vetch to that of a pigeon's egg. These contain an 
atheromatous matter, and are of various forms, some 
being sessile, globular, or flatfish, and some attached by 
a neck, and pendulous.* The growth of the tubercles 
is apparently unconnected with any constitutional dis- 
order; they show no tendency to inflammation or ul- 
ceration; but continue through life, having apparently 
no natural termination. A very extraordinary instance 
of this cutaneous deformity, which occurred in a poor 
man, who was living in good health, at Muhlberg, in 
1793, and whose body, face, and extremities, were thick- 
ly studded with these atheromatous tubercles, has been 
described by Prof. Tilesius, who has given portraits of 

* See the plate, fig. 7, v. 



280 TUBERCULA: 

the naked patient in three positions, in a pamphlet, edited 
at Leipsic, in that year, by Prof. Ludvvig. 

Since the second edition was printed, a patient was 
sent to me by a distinguished physician, affected with 
a singular species of Molluscum, which appears to be 
communicable by contact. (Plate LXI.) The face and 
neck of this young woman were thickly studded with 
round prominent tubercles, of various sizes, from that 
of a large pin's head to that of a small bean, which were 
hard, smooth and shining on their surface, with a slight 
degree of transparency, and nearly of the colour of the 
skin. The tubercles were all sessile, upon a contracted 
base, without any peduncle. From the larger ones a 
small quantity of a milk-like fluid issued, on pressure, 
from a minute aperture, such as might be made by a 
needle's point, and which only became visible on the 
exit of the fluid. The progress of their growth was very 
slow; for the first tubercle had appeared on the chin a 
twelvemonth ago, and only a few of them had attained a 
large size. Some of the latter had recently become in- 
flamed, and were proceeding to a slow and curdly sup- 
puration; and the cervical glands, lying under those on 
the neck, were also swollen, and discoloured as if pro- 
ceeding to suppurate. The eruption was still increasing 
much, and not only disfigured her greatly, but had re- 
cently impaired her general health, and occasioned a 
considerable loss of flesh, by the irritation which it pro- 
duced. 

She ascribed the origin of this disease to contact with 



VITILIGO. 28! 

the face of a child, whom she nursed, on which a large 
tubercle of the same sort existed; and on a subsequent 
visit she informed me, that two other children of the same 
family were disfigured by similar tubercles; and besides, 
that the parents believed that the first child had received 
the eruption from a servant, on whose face it was ob- 
served. Since my attention was drawn to this species of 
tubercle, I have seen it in another instance, in an infant 
brought to me with porrigo larvalis; and, on investiga- 
tion, it was found that she had apparently received it 
from an older child, who was in the habit of nursing it. 
In this case the milky fluid issued from the tubercles, 
and may be presumed to be the medium of the con- 
tagion. 

Of the best mode of managing this singular Mollus- 
cum, I have not had sufficient experience to speak. 
Nothing remedial was administered to the children; 
but in the adult patient, I had the satisfaction to find, 
that, after the liquor arsenicalis had been taken in 
small doses for a month, the tubercles were universally 
diminished both in number and magnitude, most of 
them having gradually subsided: a few, especially on the 
neck, had suppurated. 



IV. VITILIGO. 

Dr. Willan adopted this generic term from Celsus, 
but proposed to appropriate it to a disease, somewhat 

Nil 



282 TUBERCULA: 

different from those to which that classical writer ap- 
plied it, and which is not of frequent occurrence. 
There is, indeed, a substantial reason for not adopting 
the term in the acceptation in which it is used by Cel- 
sus; namely, that he has comprehended under it three 
forms of disease, two of which are generically distinct 
from the third. The two former, alphas and melas, 
are superficial, scaly diseases, i. e. only slighter varie- 
ties of lepra and psoriasis; whereas the last, leuce, 
deeply affects the skin and subjacent structure, occa- 
sioning a loss of sensibility, and ultimately of vitality, 
in those parts.* 

The disease, which is here intended to be designated 
by the term Vitiligo, (Plate LX. Fig. 2.) is, as I have 
already stated, somewhat rare, and perhaps but little 
known. It is characterized by the appearance of smooth- 
white, shining tubercles, which rise on the skin, some- 
times in particular parts, as about the ears, neck, and 
face, and sometimes over nearly the whole body, inter- 
mixed with shining papulae. They vary much in their 
course and progress: in some cases they reach their full 

* See lepra al/ihoides, above, p. 30. After having described 
the characteristics of the three forms of Vitiligo, Celsus thus- 
points out the circumstances which mark the greater severity of 
the last: " Alfihos et Melas in quibusdam variis tcmporibus et 
oriuntur et desinunt: Leuce quern occupavit, non facile dimittit. 
Priora curationem non difficillimam recipiunt ; ultimum vix up* 
quam sanescit ; ac siquid ei vitio demptum est, tamen non ex toto 
<anus color redditur." De Medicina, lib. v. cap. 28. 



VITILIGO. 283 

size in the space of a week, (attaining the magnitude of 
a large wart,) and then begin to subside, becoming 
flattened to the level of the cuticle in about ten days: 
in other instances, they advance less rapidly, and the 
elevation which they acquire is less considerable; in fact, 
they are less distinctly tubercular. But in these cases 
they are more permanent; and as they gradually sub- 
side to the level of the surface, they creep along in one 
direction, as for example, across the face or along the 
limbs, chequering the whole superficies with a veal- 
skin appearance.* All the hairs drop out, where the 
disease passes, and never sprout again, a smooth shining 
surface, as if polished, being left, and the morbid white- 
ness remaining through life. The eruption never goes 
on to ulceration. 

There is no considerable constitutional disorder com- 
bined with this affection ; but it has proved exceedingly 
unmanageable under the use of both internal and ex- 
ternal medicines. The mineral acids internally, and 
the application of diluted caustic and spirituous sub- 
stances externally, have been chiefly employed, but with 
little obvious effect 

* This white and glistening appeai'ance, bearing some resen> 
folance to the flesh of calves (vituli,) seems to have given rise to 
the generic term, 



284 TUBERCULA 



V. ACNE. 



This genus is characterized by an eruption of distinct, 
hard, inflamed, tubercles, which are sometimes perma- 
nent for a considerable length of time, and sometimes 
suppurate very slowly and partially. They usually appeal 
on the face, especially on the forehead, temples, and 
chin, and sometimes also on the neck, shoulders, and 
upper part of the breast; but never descend to the lower 
parts of the trunk, or to the extremities. As the pro- 
gress of each tubercle is slow, and they appear in suc- 
cession, they are generally seen at the same time in the 
various stages of growth and decline; and, in the more 
violent cases, are intermixed likewise with the marks or 
vestiges ot those which have subsided. The eruption 
occurs almost exclusively in persons of the sanguine 
temperament, and in the early part of life, from the age 
of pubertyf to thirty or thirty-five; but, in those of 

* This term is borrowed from Aetius, who mentions it as a sy- 
nonym of «jv0*s, by which most of the Greek writers designate 
the disease. Aet. tetrab. ii. serm. iv. cap. IS. The Latins deno- 
minated the tubercles vari. See Culsus, lib. vi. cap. 5. — Plin. Hist. 
Nat. lib. xxiii. — Sennert having spoken of the affinity of vari with 
the pustules about the head, called fisydracia by some writers, 
Sauvages made the eruption a species of the latter, Psydracia acne. 
Nosol. Meth. class i. ord. ii. gen. 9. See Jul. Pollux, Onomasticon, 
lib. iv. cap. 25. 

t From this circumstance, both the Greek appellations appear 
to have originated ; <«vft>s> from its occurring during the growth 



ACNE. 285 

more exquisite temperament, even later. It is common 
to both sexes; but the most severe forms of it are seen 
in young men. 

There are four varieties of this eruption, which may 
be designated by the titles of Acne simplex, punctata, 
indurata, and rosacea* 

1. The Acne simplex (Plate LXII.) is an eruption of 
small vari, which appear singly, and are not very numer- 
ous, nor accompanied by much inflammation, nor by 
any intermediate affection of the skin. When it has 
continued some time indeed, a little roughness of the 
face is produced, where the larger tubercles have dis- 
appeared, in consequence of a slight cracking or dispo- 
sition to exfoliate in the new cuticle; but these marks 
are not permanent. 

Many of the tubercles do not proceed to suppuration; 
but gradually rise, become moderately inflamed, and 
again slowly subside, in the course of eight or ten days, 

of the lanugo, or first beard, which the word also signifies ; — and 
*kvv, quasi cucpy, from its appearance at the acme or fu)l growth 
and evolution of the system. " lonthi, flores cum papulis circa 
faciem, vigoris signum," is the definition given by Julius Pollux 
(loc. cit,). And Cassius, in his 33d problem, explains, " Cur in 
facie vari prodeunt fere in ipso aetatis flore vigoreque (quapropter 
et axpxs, id est vigores, idiotarum vulgus eos nuncupat ?") 

* A.iuert has not figured any specimen of Acne, unless an ill- 
defined plate (22d,) representing what he calls "Dartre pustu- 
leuse mHiaire," on the forehead, be intended for Acne simplex. 



2S6 TUBERCULA: 

leaving a transient purplish red mark behind. But 
others go on to a partial suppuration, the whole process 
of which occupies from a fortnight to three weeks. The 
tubercles are first felt in the skin, like a small hard seed, 
about the size of a pin's head, and enlarge for three or 
four days, when they begin to inflame: about the sixth 
or seventh day they attain their greatest magnitude, and 
are then prominent, red, smooth, and shining, and hard 
and painful to the touch. After two or three days more, 
a small speck of yellow matter appears on the apices of 
some of the tubercles; and, when these afterwards break, 
a thinner humour is secreted, which soon dries into a 
yellowish scab. The inflammation now gradually de- 
clines, the size and hardness of the tubercles diminish, 
and the small scab becomes loosened at the edges, and 
at length falls off about the third week. The individual 
tubercles, which rise and suppurate in succession, pass 
through a similar course. 

This eruption recurs frequently, at short intervals, in 
some individuals, who have it partially; but in others, 
who are more strongly predisposed to it, it is more ex- 
tensive, and never wholly disappears, but is, at uncertain 
periods, more or less troublesome. Such persons often 
enjoy good health, and cannot refer the cutaneous com- 
plaint to any obvious exciting cause; whence Dr. Dar- 
win* has constituted it a distinct species, with the epi- 

* Dr. Darwin names the genus gutta rosea, of which, he says, 
there are three species: — 1. The gutta rosea hefiatica, connected 
with diseased liver in drunkards: 2, G. R. stomatica, which is oc- 



ACNE. 287 

thet, ''hereditary:" which, in fact, is to ascribe it solely 
to the temperament of the patient, or to consider the 
predisposition, arising from the great vascularity of the 
skin in sanguine habits, as adequate to give rise to the 
eruption, under ordinary stimulation. There appears, 
however, to be no 'clear distinction between the sto- 
machic and hereditary cases of Acne, as Dr. Darwin 
supposes; for it is only where there is a strong constitu- 
tional predisposition, that substances which disorder the 
stomach excite the eruption of Acne; and in those who 
are so predisposed, the vari occasionally appear after 
eating heartily, or drinking an unusual portion of wine, 
or from any slight cause of indigestion ; as well as after 
any inordinate excitement of the cutaneous circulation 
from violent exercise in hot weather, or in heated rooms, 
especially when followed by a copious draught of cold 
liquor. In some cases, a sort of critical eruption of vari 
has suddenly occurred, after severe indigestion, or con- 
tinued pains in the stomach, which have been immedi- 
ately relieved; and in such instances, there is occasion- 
ally also an eruption of lichenous papulae on the body 
and limbs. 

casio.ned by taking cold drink, eating cold raw turnips, &c. when 
the body is much heated by exercise; and 3. The G. rosea here- 
ditaria, or puncta rosea (the Acne simplex), which consists of 
smaller pimples, that are less liable to suppurate, and which 
seems to be hereditary, " or at least has no apparent cause like 
the others." See Zoonomia, class, ii. 1. 4. 6.— and class, iv. 1.2 
13. and 14. 



288 TUBERCULA 

Being generally, however, a local disease, the Acne 
simplex is to be treated chiefly by external applications. 
Except in females, indeed, this variety of the eruption 
seldom calls for the attention of medical men. Celsus 
observes that, in his time, the Roman ladies were so 
solicitous of maintaining their beauty, that he deemed 
it necessary to mention the remedies for this affection, 
which otherwise he considered as too trifling for the 
notice of the physician.* The ancients agree in re- 
commending a number of stimulant applications, with 
the view of discussing the " thick humours" which were 
supposed to constitute the vari. Lotions and liniments 
containing vinegar and honey, sometimes combined with 
an emulsion of bitter almonds, and sometimes with tur- 
pentine, resin myrrh, and other gums, or with alum, 
soap, and Cimolian earth, or the bruised roots of the 
lily, cyclamen, narcissus, &c. were the substances which 
they principally employed.! They were, doubtless, cor- 
rect as to the principle; as a gentle stimulus to the skin 
is the most safe and effectual remedy. The apprehen- 
sions, which have been strongly expressed by the hu- 

* " Pene ineptiae sunt, curare varos, et lenticulas, et ephe'idas : 
seel eripi tamen foe minis cura cultus sui non potest." De Med. 
lib. vi. cap. v. 

t See Celsus, loc. cit. — Oribas. Synops. lib. viii. cap. 34; and 
De Loc. Affect, lib. iv. cap. 51 — Aetius, tetr.ib. ii. sertn. iv. cap. 
13. — Paulus, lib. iii. cap. 25. — Actuarius, lib. iv. cap. 12. By the 
older modern writers, who were chiefly their copyis's. the same 
applications were prescribed. See Hafenreffer, Nosodochium, lib. 
ii. cap. 14. 



ACNE. 289 

moral pathologists, of producing internal disorder by the 
sudden repulsion, as it has been called, of these cutane- 
ous eruptions, are not altogether hypothetical. Head' 
ache, and affections of the stomach and bowels, have 
sometimes been thus produced, which have ceased on 
the re-appearance of the eruption: but, on the whole, 
as far as my observation goes, this alternation of disease 
is less frequent and obvious in this form of Acne, than 
in the pustular and crustose eruptions of the face and 
head. 

The stimulant applications, which are most easily 
proportioned to the irritability of the tubercles, are 
lotions containing alcohol, which may be reduced or 
strengthened, according to circumstances, by the addi- 
tion of any distilled water. It is not easy to describe 
the appearances of the eruption, which indicate any 
certain degree of strength in the lotion: but a little 
observation will teach this discrimination. If the tu- 
bercles are considerably inflamed, and a great number 
of them pustular, a dilute mixture will be requisite; 
containing, for example, equal parts of spiritus tenuior, 
and of rose or elder-flower water. The effect of a 
very acrid lotion, under such circumstances, is to mul- 
tiply the pustules, to render many of them confluent, 
and to produce the formation of a crust of some extent, 
as well as to excite an inflammatory redness in the ad- 
joining skin.* A slight increase of the inflammation, 

* It must be admitted, however, that the eruption is sometimes 
materially diminished, after the violent action of an irritating ap« 
O 



290 TUBERCULA: 

indeed, is sometimes occasioned by the first application? 
of a weak stimulus; but this is of short duration; and 
the skin soon bears an augmentation of the stimulant; 
until at length the pure spirit is borne with advantage, 
as the inflammatory disposition subsides. Under the 
latter circumstances, even a considerable additional sti- 
mulus is often useful: such as from half a grain to a grain 
or more of the muriate of mercury, in each ounce of the 
spirit; or a drachm or more of the liquor potassag, or of 
the muriatic acid, in six ounces. Acetous acid, as 
recommended by the ancients, and the liquor ammonias 
acetatis, afford also an agreeable stimulant, in proper 
proportions. Sulphur yields a small portion of its sub- 
stance to boiling water, poured upon it, and allowed to 
infuse for twelve or fourteen hours, a quart of water 
being added to about an ounce of broken sulphur. A 
lotion of this nature has been found advantageous, in 
slight cases of Acne simplex, and especially in removing 
the roughness and duskiness of the face connected with 
it* 

plication has subsided. I lately saw a lady, who considered her- 
self much benefited after a severe inflammation, and even excoria- 
tion, of the face, which had been produced by a poultice of bruised 
parsley. ' Dr. Darwin affirms that blistering the whole face, in 
small portions, successively, is the most effectual remedy for this 
Acne. (Joe. cit.) But the " cura cultus sui" generally renders 
patients of this class unwilling to employ harsh remedies. 

*This lotion has been recommended by Dr. Clarke of Dublin, 
as containing a sufficient impregnation of sulphur for the cure of 
scabies in children. See Med. Facts and Observ. vol. viii. p. 275. 



ACNE. 291 

2. Acne punctata. (Plate LXII.) The eruption, in 
this variety of the disorder, consists of a number of black 
points, surrounded by a very slight raised border of cu- 
ticle. These are vulgarly considered as the extremities 
of small worms or grubs, because, when they are pressed 
out, a sort of wormlike appendage is found attached 
to them: but they are in fact only concreted mucus or 
sebaceous matter, moulded in the ducts of the sebaceous 
glands into this vermicular form, the extremity of which 
is blackened by contact with the air. In consequence 
of the distention of the ducts, the glands themselves 
sometimes inflame, and form small tubercles, with little 
black points on their surface, which partially suppurate, 
as in the foregoing species: but many of them remain 
stationary for a long period, without ever passing into 
the inflammatory state. Not unfrequently they are in- 
termixed with a few tubercles, in which the puncta have 
not appeared. 

These concretions may be extracted, by pressing on 
both sides of the specks with the nails, until the hard- 
ened mucus is sufficiently elevated to be taken hold of. 
A blunt curved forceps may be employed with advan- 
tage for this purpose.* When the puncta are removed, 
the disease becomes Acne simplex, and requires the 
same treatment with the preceding species. 

Dr. Underwood has recommended the use of a solu- 

* Such a forceps has been contrived by a surgeon's instrument- 
maker, of the name of Hattersley, in South Molton-street. 



292 TLBERCULA: 

tion of carbonate of potass internally, in these cases;* 
and Dr. Willan was in the habit of occasionally pre- 
scribing the oxymuriate acid. One or two tea-spoon- 
fuls of this liquid, taken in a glass of water three times 
a day. for a considerable period, has sometimes appeared 
to benefit the health, and improve the colour and smooth- 
ness of the skin; but, on the whole, it is not easy to 
discover any sensible operation of this medicine, and its 
only effect is, perhaps, that of a tonic to the stomach 
Medicines of this nature are more adapted to the sub- 
sequent species of the complaint, especially to the A. 
rosacea. 

3. Acne mdurctta. (Plate LXIII.) In this form of 
Acne, the tubercles are larger, as well as more indurated 
and permanent, than in A. simplex. They rise often in 
considerable numbers, of a conical, or oblong conoidal 
form, and are occasionally somewhat acuminated, as if 
tending to immediate suppuration, being at the same time 
of a bright roseate hue: yet many of them continue in 
a hard and elevated state for a great length of time, 
without any disposition to suppurate. Others, however, 
pass on very slowly to suppuration, the matter not being 
completely formed in them for several weeks, and then 
only a small part of the tubercles are removed by that 

* See some observations relative to "crinone,?, or grubs," which 
he says, he had often found troublesome, especially in females, 
about the time of puberty. Treatise on the Dis. of Children, voL 
ii. p. 167, 5th edit. 



ACNE. 2 93 

process. Sometimes two or three coalesce, forming a 
large irregular tubercle, which occasionally suppurates 
at the separate apices, and sometimes only at the largest. 
In whatever mode they proceed, the vivid hue of the tu- 
bercles gradually becomes more purple or even livid, es- 
pecially in those which show no tendency to suppurate. 
Slight crusts form upon the suppurating tubercles, which 
after some time fall off, leaving small scars, surrounded 
by hard tumours of the same dark red colour; and these 
sometimes suppurate again at uncertain periods, and 
sometimes slowly subside and disappear, leaving a purple 
or livid discoloration, and occasionally a slight depres- 
sion, which is long in wearing off. 

The tubercles, even when they do not suppurate, but 
especially while they continue highly red, are always 
sore, and tender to the touch, so that washing, shaving, 
the friction of the clothes, &c. are somewhat painful. 
In its most severe form, this eruption nearly covers the 
face, breast, shoulders, and top of the back, but does not 
descend lower than an ordinary tippet in dress: yet 
this limitation of the disorder is independent of the ex- 
posure of those parts; for it occurs equally in men and 
women. In a few instances in young men, I have seen 
an extensive eruption of Acne indurata, affecting these 
covered parts, while the face remained nearly free from 
it. By the successive rise and progress of the tumours, 
the Whole surface, within the limits just mentioned, was 
spotted with the red and livid tubercles, intermixed with 
the purple discolorations and depressions, left by those 



394 TUBEROULA: 

which had subsided, and variegated with yellow suppu- 
rating points and small crusts, so that very little of the 
natural skin appeared. Sometimes the black puncta of 
the sebaceous ducts were likewise mixed with the vari 
and their sequelae. 

The general health does not commonly suffer, even 
under this aggravated form of the eruption.* If a 
fever or other severe disease should take place, indeed, 
the tubercles often subside and disappear: so that their 
recurrence, under such circumstances, is to be deemed 
a sign of returning health. I have seen the erethism 
of a mercurial course, administered for other purposes, 
occasion the disappearance of this Acne, which re- 
turned with the restoration of flesh and strength, after 
the omission of the medicine. Many persons, how- 
ever, who are affected with the eruption, are liable to 
disorders of the bowels and stomach, to haemorrhoids, 
and some to phthisis pulmonalis. Its first appearance, 
too, is commonly ascribed to some irregularity of diet, 
or to some cold substance swallowed when the person 

* Forestus, and several other physicians of the sixteenth cen- 
tury, assert that vari are the precursors of elephantiasis, and in- 
dicate its approach. Sennertus asserts the same of vari, that are 
accompanied with puffy swelling (inflatio) of the face, and hoarse- 
ness. But these assertions are obviously either the result of mere 
hypothesis, founded on the resemblance of the larger vari to the 
incipient tubercles of elephantiasis ; or of practical error, in ap- 
plying the appellation -of vari to the early symptoms of the latter 
disease. See Forest. Obs. Chirurg. lib. v. obs. 7. Sennert. Med. 
Pract. lib. v. part. ii. cap. 23. 



ACNE. 295 

had been overheated, and was in a free perspiration. 
Hence the first eruption is not unfrequently sudden. 

The Acne indurata is often much alleviated, and 
sometimes entirely removed, by the steady use of ex- 
ternal stimulants, combined with a proper regulation of 
the diet and exercise. The eruption will bear a more 
acrid stimulus, even from the beginning, than the in- 
flamed Acne simplex. A spirituous lotion, at first a 
little diluted, and containing the oxymuriate of mer- 
cury, in the proportion of a grain or somewhat less to 
the ounce of the vehicle, is often extremely beneficial. 
Gowland"s lotion, an empirical preparation, which is 
said to contain this mercurial salt in an emulsion of 
bitter almonds,* is popularly used; and where its 
strength happens to accord with the degree of irritabi- 
lity in the eruption, and it is not applied to the other 
varieties of it, it is doubtless beneficial. Many other 
stimulant?, some of which have been already named, 
may be substituted, of course, with similar effect; but 
it is unnecessary to specify them. It will be proper to 
remark, that, in general, it is requisite to augment the 
activity of all these applications, in the progress of the 
treatment, partly in consequence of the diminished ef- 
fect of an accustomed stimulus, and partly on account 

* The bitter almond was a favourite application with all the an- 
cient physicians in inflammatory cutaneous eruptions. Its emul- 
sion is prescribed, as a vehicle of more active substances, in every 
tract which they have left on these subjects. Yet it is probably a 
mere agreeable mucilage. 



296 TUBERCULA. 

of the increasing inertness of the tubercles, as the in- 
flammatory state subsides, which must be determined by 
the appearances. 

Frequent purgatives, which are often resorted to in 
these cases, especially by unprofessional persons, among 
whom the dregs of the humoral pathology still remain, 
are of no advantage; but, on the contrary, often aug- 
ment the disease, in feeble habits. The copious use 
of raw vegetables in diet, which the misapplication of 
the term " scurvy" has introduced, is likewise to be de- 
precated, as well as the free use of vegetable acids, es- 
pecially in constitutions that are predisposed to indi- 
gestion. These substances not only afford little nutri- 
ment, under such circumstances, but tend to increase 
the indigestion: and it is a fact, which it may not be 
easy to explain, that, under many modifications of cu- 
taneous inflammation, especially about the head and 
face, that inflammation is immediately increased in sym- 
pathy with the offended stomach, when these substances 
arc eaten.* It were totally superfluous to remind profes- 
sional men of the very opposite nature of inflammatory 
and suppurating affections of the skin, to that of 
petechias and ecchymoses, the mere effusions of extra- 
vasated blood under the cuticle, which belong to the 
proper, or, as it has been called, the putrid scurvy. 
And this negative inference at least must be deduced 
from the fact, that it is almost impossible, that these two 

* See above, p. 17, note. 



ACNE. 2Q1 

opposite states of disease should be benefited by the 
same remedies. The diet, in these cases of Acne, 
should be good, i. e. light, and nutritious, but not stimu- 
lating; consisting of animal food, with well-dressed ve- 
getables, and thefarinacea3; wine and fermented liquors 
being omitted, or taken with great moderation. 

Internally, medicines effect very little; but I have 
had an opportunity, in several severe cases of Acne tu- 
berata, of witnessing the increased amendment of the 
disorder, under the external treatment already mentioned, 
when small doses of soda, sulphur, and antimony were 
at the same time administered; by which plan the skin 
has been totally cleared. 

4. Acne rosacea.* (Plate LXIV.) This form of 
Acne differs in several respects from the preceding spe- 
cies. In addition to an eruption of small suppurating 
tubercles, there is also a shining redness, and an irre- 
gular granulated appearance of the skin of that part of 
the face which is affected. The redness commonly ap- 
pears first at the end of the nose, and afterwards spreads 
from both sides of the nose to the cheeks, the whole of 
which, however, it very seldom covers. In the com- 
mencement it is not uniformly vivid; but is paler in the 
morning, and readily increased to an intense red after 

* This is the gutta rosea, or rosacea of authors; some of whom, 
however, (as Dr. Darwin, to whom I have already referred,) com- 
prehend all the varieties of vari under that appellation. 



m TUBERCULA 

dinner, or at any time if a glass of wine or spirits be 
taken, or the patient be heated by exercise, or by sitting 
near a fire. After some continuance in this state, the 
texture of the cuticle becomes gradually thickened, and 
its surface uneven or granulated, and variegated by re^ 
ticulations of enlarged cutaneous veins, with smaller 
red lines stretching across the cheeks, and sometimes 
by the intermixture of small suppurating vari, which 
successively arise on different parts of the face. 

This species of Acne seldom occurs in early life, ex- 
cept where there is a great hereditary predisposition to 
it, in general it does not appear before the age of forty ; 
but it may be produced in any person by the constant 
immoderate use of wine and spirituous liquors. The 
greater part of the face, even the forehead and chin, 
are often affected in these cases; but the nose especially 
becomes tumid, and of a fiery red colour; and, in ad- 
vanced life, it sometimes enlarges to an enormous size: 
the nostrils being distended and patulous, or the alas fis- 
sured, as it were, and divided into several separate lobes*. 

* Sennert mentions a case, in which the enlarging nose made 
such an approximation in magnitude to Strasburg steeple, as to 
impede the exercise of vision, and to require lopping. " Sumunt 
tubercula ista interdum incrementum, ut fades inaequalis et hor- 
rida evadat. et nasus valde augeatur. Vixit superiori adhuc anno, 
non procul a Dresda, vir, cui hoc malo affecto, nasus ita incre- 
mentum sumsit, ut eum in legendo impjsdiret ; quod malum ip- 
sum ed adegit, ut anno 1629 particulas quasdam de naso sibi ampu- 
tari curaret." Pract, Med. lib. v. part. i. cap. 31. 



ACNE. 299 

At that period of life too, the colour of the Acne rosa- 
cea becomes darker and more livid; and if suppuration 
take place in any of the tubercles, they ulcerate unfa- 
vourably, and do not readily assume a healing disposi- 
tion. 

In young persons, however, who are hereditarily pre- 
disposed to this complaint, irregular red patches not un- 
frequently appear in the face, which are often smooth, 
and free from tubercles, and sometimes throw off slight 
exfoliations at intervals. These patches may be gradu- 
ally extended, if great temperance both in food and drink 
be not observed, until the whole face assume a preter- 
natural redness. 

As this eruption is chiefly sympathetic of some de- 
rangement of the chylopoetic viscera, or of a peculiar 
irritability of the stomach, little advantage can be ex~ 
pected from local applications: and, in fact, the stimu- 
lants, which are beneficial, under proper regulations, in 
most of the other forms of Acne, are generally prejudi- 
cial in this, and aggravate the complaint. The misap- 
plication of the nostrum, before mentioned, to this varie- 
ty of the eruption, is one among the numerous practical 
errors, which originate from the indiscriminate recom- 
mendations of empiricism. On the other hand, all strong 
sedatives or restringents, if they succeed in repressing 
the eruption, are liable to aggravate the internal disorder. 

The perfect cure of Acne rosacea is, in fact, seldom 
accomplished; for whether it originate in a strong here- 
ditary predisposition, or from habitual intemperance, the 



300 TUBERCULA 

difficulties in the way of correcting the habit of body, 
are almost insurmountable. The regulation of the diet, 
in both cases, is important: and when the stomach or 
liver is disordered, in the latter, the symptoms may be 
sometimes palliated by the liquor potassae, or other an- 
tacids, which seem also to have some influence in les- 
sening inflammatory action in the skin. The gentlest 
resiringents should be used externally to the patches of 
reticulated veins; such as very dilute spirituous or ace- 
tous lotions, with or without a small proportion of the 
acetate of lead; or simple ointments combined with alum, 
acetate of lead, &x. in small quantities. The more 
purely local and primary the eruption appears to be, the 
more active may be the astringency of the substances 
applied to it. 



VI. SYCOSIS. 

Although this eruption was not mentioned in the enu- 
meration of tubercles, on the cover of Dr. Willan's pub- 
lication, I believe he intended, after the example of the 
old writers, to introduce it in this place, in consequence 
of its affinity to acne. 

The Sycosis* consists of an eruption of inflamed but 

* This denomination has been given to the disease, from the 
granulated and prominent surface of the ulceration which ensues, 
and which somewhat resembles the soft inside pulp of a Jig (<rvxov) 
" Est etiarn ulcus, quod :>fici simiiitudine c-vKurts a Gi aecis nomi- 
natur, quia caro in eo excrescit." Celsus, lib. vi. cap. 3. The 



SYCOSIS. 



301 



not very hard tubercles, occurring on the bearded por- 
tion of the face and on the scalp, in adults, and usually 
clustering together, in irregular patches. Celsus has 
correctly stated, that some difference takes place in the 
appearance and progress of the eruption, when it is seat- 
ed in the chin, and in the scalp; whence he divides it 
into two species * 

1. In the Sycosis menti, (Plate LXV.) the tubercles 
arise first on the under lip, or on the prominent part of 
the chin, in an irregularly circular cluster: but this is 
speedily followed by other clusters, and by distinct tu- 
bercles, which appear in succession, along the lower 
part of the cheeks up to the ears, and under the jaw 

later Greeks, however, apply the terms o-vkx, and oynoi e-vKafois, 
(Jici, andjicose tumours,) to excrescences of the eyelids, as well 
as to the proper Sycosis of Celsus. See Aetius, tetrab. i. serm. ii. 
cap. 80 & 190; — also tetr. ii. serm. iii. cap. 43 ; — Paul. iEgin. lib. 
iii. cap. 22 ; — and Actuarius, lib. ii. cap. 7. Paul, however, de- 
scribes the Sycosis of the face as an eruption of" round, red, some- 
what hard, painful, and ulcerating tubercles." (lib. iii. cap. 3.) 
And Aetius, in another place, mentions the eruption as " one of 
the affections of the chin, which," he says, " differs from acne, in 
the nature of the humour, which it discharges, and in its greater 
tendency to ulceration." (tetrab. ii. serm. iv. cap. 14.) 

* " Sub eo vero duse sunt species. Altera ulcus durum et ro- 
tundumest; altera humidum et inaequale. Ex duro exiguum 
quiddam et glutinosum exit ; ex humido plus, et mali odoris. Fit 
utrumque in iis partibus quae pilis conteguntur: sed id quod cal- 
losum et rotundum est maxime in barba ; id vero, quod humidum, 
praecipue in capillo." loc. cit. 



S02 TUBERCULA: 

towards the neck, as far as the beard grows/ The 
tubercles are red and smooth, and of a conoidal form, 
and nearly equal to a pea in magnitude. Many of them 
continue in this condition for three or four weeks, or 
even longer, having attained their full size in seven or 
eight days; but others suppurate very slowly and par- 
tially, discharging a small quantity of thick matter, by 
which the hairs of the beard are matted together, so 
that shaving becomes impracticable, from the tender 
and irregular surface of the skin. This condition of the 
face, rendered rugged by tubercles from both ears round 
to the point of the chin, together with the partial ulcer- 
ation and scabbing, and the matting together of the un- 
shaven beard, occasions a considerable degree of defor- 
mity; and it is accompanied also with a very troublesome 
itching. 

This form of the Sycosis occurs, of course, chiefly 
in men; but women are not altogether exempt from it 
though it is commonly slight, when it appears in them. 
Its duration is very uncertain: it is commonly removed 
in about a fortnight; but sometimes the slow suppura- 
tion goes on for mauy weeks; and sometimes the sup- 
purating tubercles heal, and again begin to discharge. 
Occasionally the disease disappears for a season, and 
breaks out again. 

* An indifferent representation of this disease is given by Ali- 
bert, plate 20, under the appellation of " dartre pustuleuse men- 
tagro." 



SYCOSIS. 303 

'2. The Sycosis capillitii* (Plate LXVI.) is seated 
chiefly about the margin of the hairy scalp, in the occi- 
put, or round the forehead and temples, and near the 
external ear, which is also liable to be included in the 
eruption. The tubercles rise in clusters, which affect 
the circular form; they are softer and more acuminated, 
than those on the chin; and they all pass into suppura- 
tion in the course of eight or ten days, becoming con- 
fluent, and producing an elevated, unequal, ulcerated 
surface, which often appears granulated, so as to afford 
some resemblance to the internal pulp of a fig. The 
ulceration, as Celsus states, is generally humid; for there 
is a considerable discharge of a thin ichorous fluid, 
which emits an unpleasant rancid odour. 

The Sycosis, under its first-mentioned form, may be 
distinguished from acne indurata, by its seat being ex- 
clusively on the bearded part of the face, — by the softer, 
more numerous, and clustered tubercles, — and by the 
ulceration which they tend to produce. And, under its 
second form, in which it is somewhat assimilated to the 
eruption of favous pustules, or porrigo favosa, affecting 
the face and the borders of the capillitium, it may be 
discriminated, by the tuberculated and elevated base of 
the suppurating tumours; not to mention the adult age 
of the patient, and the absence of contagion. 

* M. Alibert has figured a disease of the scalp, under the ap- 
pellation of " pian ruboide," in plate 35, which resembles the Sy- 
cosis of the scalp, if it be not a case of neglected or mismanaged 
porrigo favosa. 



304, TUBERCULA: 

The cure of Sycosis is generally much more easiiy 
accomplished, than that of porrigo favosa; but the me- 
thod of treatment required for it is not very different. 
When the tubercles are numerous, inflamed, and con- 
fluent, and especially when the suppuration is either 
beginning or considerably advanced, the most speedy 
benefit is derived from the application of poultices, at 
night, of linseed powder, bread and milk, or other 
simple ingredients. In the less severe forms, warm 
ablutions or fomentations may be substituted. When 
the inflammatory symptoms are reduced, and in cases 
where they are from the first moderate, the healing' 
process is much promoted, and the discharge moderat- 
ed and restrained, by the application of the unguentum 
hydrargyri nitrati, diluted with three or four parts of 
simple ointment, or by the ung. hydrarg. praecipitat. 
united with an equal portion of the zinc ointment, or 
the cerate of acetate of lead. At the same time it is 
useful to prescribe antimonials, with alterative doses of 
mercury, followed by cinchona, or serpentaria, and the 
fixed alkalis, especially where there appears to be any 
affection of the digestive organs, which not unfrequently 
concurs with this eruption. 



VII. lupus. 

Of this disease I shall not treat at any length; for I 
can mention no medicine, which has been of any essen- 
tial service in the cure of it, and it requires the con- 



sycosis. 305 

slant assistance of the surgeon, in consequence of the 
spreading ulcerations, in which the original tubercles 
terminate.* (Plate LXVII.) 

The term was intended by Dr. Willan to comprise, 
together with the " noli me tangere" affecting the nose 
and lips, other slow tubercular affections, especially 
about the face, commonly ending in ragged ulcerations 
of the cheeks, forehead, eyelids, and lips, and some- 
times occurring in other parts of the body, where they 
gradually destroy the skin and muscular parts to a con- 
siderable depth. Sometimes the disease appears in the 
cheek circularly, or in the form of a sort of ring-worm, 
destroying the substance, and leaving a deep and de- 
formed cicatrix: and I have seen a similar circular patch 
of the disease, dilating itself at length to the extent of 
a hand-breadth or more, upon the pectoral muscle. 

By surgical means, i. e. by the knife or the caustic, a 
separation has sometimes been made of the morbid from 
the sound parts, and the progress of the disease arrested. 
And in some cases, where the ulceration was very slow, 
and unaccompanied by much inflammation, the internal 
use of arsenic has been found beneficial; a circumstance 
which has probably given rise to the opinion, that can- 

* Alibert has two admirable portraits of Lupus in the face, in 
plates 19 bis , and 21; the former of noli me tangere, which he 
calls "dartre rongeante scrophuleuse;" and the latter of a less 
malignant variety, which he terms " dartre pustuleuse couperose.'* 
His 19th plate is apparently an incipient Lupus of the ala nasi, 
under the appellation of " dartre rongeante idiopathiqqe." 



30b TUBKRCULA: 

cer has been cured by that mineral. In three or four 
less severe cases of lupous tubercles in the face, which 
had made no progress towards ulceration, I have seen 
the solution of muriate of barytes, taken internally, ma- 
terially amend the complaint. 

VIII. ELEPHANTIASIS. 

As the Elephantiasis (Plate LXVIII.) is almost un- 
known in this country, and I have only seen two in- 
stances of the disease, I must speak of it principally as 
it is described in books; and should have omitted the 
subject altogether, had it not appeared to me that some 
comment on the mistakes of translators and their fol* 
lowers, as well as on the history of the disease in gene- 
ral, might contribute to put the matter in a clearer light, 
than that in which it now stands. 

The Elephantiasis (as described by the Greeks*) is 

* The terms tXtQccs and eXeQavrtxTis were applied to this tuber- 
cular disease by Aretaeus, and the succeeding Greek writers, 
partly perhaps on account of some resemblance of the diseased 
skin to that of the elephant ; but principally from the formidable 
severity and duration of the disease. " For it is disgusting to the 
sight," says Aretsees, " and in all respects terrible, like the beast 
of similar name." (De Diuturn. Morb. lib. ii. cap. 13.) And 
Aetius observes, " Elephantiasis quidem a magnitudine et diu- 
turnitate nomen accepit." (tetrabibl. iv. serm. i. cap. 120.) So 
also the poet : 

" Est leprae species, elephantiasisque vocatur, 
Quae cunctis morbis major sic esse videtur 
Ut major cunctis elephas animantibus exstat." 

Macer de Herbar. Virtut. 



ELEPHANTIASIS. 307 

principally characterized by the appearance of shining 
tubercles, of different sizes, of a dusky red, or livid co- 
lour, on the face, ears, and extremities; together with a 
thickened and rugous state of the skin, a diminution or 
total loss of its sensibility, and a falling off of all the hair, 
except that of the scalp. 

The disease is described as very slow in its progress, 
sometimes continuing for several years, without materi- 
ally deranging the functions of the patient. During 
this continuance, however, great deformity is gradually 
produced. The ate of the nose become swelled and 
scabrous, and the nostrils dilate; the lips are tumid; the 
external ears, particularly the lobes, are enlarged and 
thickened, and beset with tubercles; the skin of the 
forehead and cheeks grows thick and tumid, and forms 

The same disease was described by the Arabians, under the ap- 
pellation of Juzam or Judam, and is still designated by similar 
terms in Arabia and Persia, viz. Dsjuddam, and Madsjuddam, ac- 
cording to Niebuhr. (Description de P Arabic, torn. iii. p. 119.) 
The translators, however, of the works of the Arabian physicians 
into Latin committed an extraordinary blunder, in rendering this 
appellation by the Greek term lepras by which they misled their 
brethren, (who henceforth called Elephantiasis, the Arabian lepra- 
&y,) and contributed to introduce much confusion both into medi- 
cal and popular language in the use of the term. The Arabians 
have not employed the word lepra ; but have designated the va- 
rieties of scaly and tubercular diseases by appellations, in their 
own language, as distinct and definite as those of the Greeks. 
(See Avicenna, lib. iv. fen. 3. tract. 3. — Alsaharavius, tract. 31.— 
Haly Abbas, Theorice, lib. viii. cap. \S. and Praet. cap. 14.*— . 
Avenzoar, lib. ii.) 



308 TUBERCULA: 

large and prominent rugae, especially over the eyes: the 
hair of the eye-brows, the beard, the pubes, axilla?, &.c. 
falls off; the voice becomes hoarse and obscure ; and the 
sensibility of the parts affected is obtuse, or totally abo- 
lished, so that pinching or puncturing them gives no un- 
easiness. This disfiguration of the countenance suggest- 
ed the idea of the features of a satyr or a wild beast; 
whence the disease was by some called Satyriasis* and 
by others Leontiasis.j 

As the malady proceeds, the tubercles begin to crack, 
and at length to ulcerate: ulcerations also appear in the 

* The term satyriasis, or satyriesmos, was also deemed appli- 
cable to the disease, on account of the excessive libidinous dispo- 
sition said to be connected with it. See Aretaeus, loc. cit. and 
Aetius, tetrab. iv. serm. i. cap. 120. 

t The two Greek writers, just quoted, attribute this name to 
the laxity and wrinkles of the skin of the forehead, which resem- 
bles the prominent and flexible front of the lion. But the Arabian 
writers ascribe it to a different source. Haly Abbas says the coun- 
tenance was called leonine, because the white of the eyes becomes 
livid, and the eyas of a round figure; and Avicenna observes that 
the epithet was applied to the disease, because it renders the coun- 
tenance terrible to look at, and somewhat of the form of the lion's 
visage, loc. cit. These appellations prove, that the allusions were 
entirely metaphorical, and did not refer to any resemblance in the 
skin of patients to the hide of these beasts. — M. Alibert has figured 
two varieties of Elephantiasis ; viz. in plate 32, under the title of 
" Lepre tuberculeuse," where it is incipient on the eye-brows; 
and in plate 34, affecting the nose and lips, where it is called 
" Lepre leontine." His " Lepre Elephantiasis," plate 33, is the 
"Barbadoes leg. 



ELEPHANTIASIS. 309 

throat, and in the nose, which sometimes destroy the 
palate and the cartilaginous septum; the nose falls; and 
the breath is intolerably offensive: the thickened and 
tuberculated skin of the extremities becomes divided by 
fissures, and ulcerates, or is corroded under dry sordid 
scabs, so that the fingers and toes gangrene, and sepa- 
rate, joint after joint* 

Aretaeus and the ancients in general consider Elephan- 
tiasis as an universal cancer of the body, and speak of it 
with terror; they depict its hideous and loathsome cha- 
racter, its contagious qualities, and its unyielding and fatal 
tendency, in strong metaphorical language, which, indeed^ 
tends to throw some doubt on the fidelity of their descrip- 
tion. The very appropriation of the name is poetical;, 
and Aretaeus lias absurdly enough prefixed to his de- 
scription of the disease an account of the elephant, in 
order to point out the analogy between the formidable 
power of the beast, and of the disease. It is probable, 
that his terrors led him to adopt the popular opinion re- 
specting the malady, without the correction of personal 
observation: for, although his account has been copied 
by subsequent writers,! and the same popular opinions 

*Alsaharavius thus states the symptoms of the juzam, when 
fully formed :— " the colour of the skin is changed, the voice is 
lost, the hairs have entirely disappeared ; the whole surface of the 
body is ulcerated, discharging a putrid sanies, with extreme foetor ; 
the extremities begin to fall off, and the eyes weep profusely." 
Lib. Practice, tract. 31. cap. 1. 

t It is impossible to read the description of this disease, (as said 
to occur at Barbadoes) by the learned Dr. Hillary, without a con- 



310 TUBERCTJLA: 

have been constantly entertained, there is much reason 
to believe, that some of the prominent features of his 
portrait are incorrectly drawn. 

Notwithstanding the care with which the separation 
and seclusion of lepers have been enforced, in compli- 
ance with the ancient opinion, there is great reason to 
believe that Elephantiasis is not contagiovs. M. Vidal 
long ago controverted that opinion, having never ob- 
served an instance of its communication from a leprous 
man to his wife, or vice versa,* although cohabiting for 
a long series of years. Dr. T. Heberden daily observed 
many examples of the same fact in Madeira, and affirms 
that " he never heard of any one who contracted the 
distemper by contact of a leper." And Dr. Adams has 
more recently given his testimony to the same truth, re- 
marking that none of the nurses in the lazar-house at 
Funchail nave shown any symptoms of the disease; and 

viction that that respectable physician had in his mind a history 
detailed by the eloquent Greek (Aretaeus,) and not the phenomena 
of the disease, as he had himself seen it. See his Obs. on the Air 
and Dis. of the Island of Barbadoes, p. 322, 2d edit. 

* See his Recherches et Obs. sur la Lepre de Martigues, in the 
Mem. de la Soc. Roy. de Med. tom.i. p. 169. — Dr. Joannis, a phy- 
sician at Aix, who investigated the disease in the lazar-house at 
Martigues, in 1755, also asserts the rarity of its communication 
between married persons. See Lond. Med. Obs. and Inquiries, 
vol. i. p. 204. — Indeed, several able physicians, two centuries be- 
fore, though bending under the authority of ancient opinion, yet 
acknowledged their astonishment at the daily commerce ot Jazar c 



ELEPHANTIASIS, 311 

that individual lazars have remained for years at home, 
without infecting any part of their family.* 

With respect to the libido inexplebilis, which is said 
to be one of the characteristics of Elephantiasis, the evi; 
dence is not so satisfactory. Its existence, however, is 
affirmed by most of the modern writers, with the excep- 
tion of Dr. Adams. MM. Vidal and Joannis mention it 
among the symptoms of the disease at Martigues.f Dr. 
Bancroft senior states its occurrence in the Elephantiasis 
of South America :| and Prof. Niebuhr asserts, that it 
appears in the Dsjuddam of Bagdat.§ But Dr. Adams ob- 
served, on the contrary, in the lazars of Madeira, an ac- 
tual wasting of the generative organs in the men, who had 
been seized with the malady subsequent to the age of 
puberty, and a want of the usual evolution of them, in 

with the healthy, without any communication of the disease. See 
kernel, de Morb. Occult, lib. i. c. 12. Forest. Obs. Chirurg. lib. iv. 
obs. 7: also the works of Fabricius, Platev, &c. Fernel, indeed; 
admits, that he never saw an instance which proved the existence 
of contagion. 

* See his Obs. on Morbid Poisons, 2d edit. chap. 18. 

f M. Vidal particularizes the case of Arnaud, a sailor, who had 
been afflicted with the tubercular Elephantiasis six months, when 
he died of a putrid fever. " II n'avoit cesse, presque jusqua sa mort 3 
de ressentir les ardeurs d'un assez violent satyriasis." 

|" Lepers are notorious for their salacity and longevity. 3 ' Nat. 
Hist, of Guiana, p. 385. 

§ Loc. cit. The story related by Niebuhr, of a lazar gratifying 
this propensity by infecting a woman by means of linen sent out 
of the lazar-house, and thus obtaining her admission, appears^ 
however, to be entitled to little credit. 



312 TUBERCULA: 

those who had been attacked previous to that period. Is 
the Elephantiasis in Madeira now less virulent than that 
of former times? has it undergone some change in its 
character? or is the ancient account of the disease in- 
correct? 

It is generally affirmed, that the Elephantiasis was 
extensively prevalent in Europe, in the middle ages, 
especially subsequent to the crusades; and it is certain, 
that every country abounded with hospitals, established 
for the exclusive relief of that disease, from the tenth to 
the sixteenth century;* and that an order of knight- 
hood, dedicated to an imaginary St. Lazarus, was insti- 
tuted, the members of which had the care of lepers, 
and the control of the lazarettoes, assigned to them, 
and ultimately accumulated immense wealth. From 
these facts, however, nothing satisfactory is to be col- 
lected, respecting the actual prevalence of Elephantiasis 
at those periods. For although it is obvious, from the 
nature of the examination instituted by the physicians 
of those lazarettoes, that the tubercular disease was the 

* The number of these establishments, however, has been greatly 
misrepresented, in consequence of an error of quotation from 
Malt. Paris, which has been echoed by several authors. That 
historian has been made to assert, that, in the thirteenth century., 
there were 19,000 lazarettoes in Christendom : whereas he only 
states that the Knights Hospitalers were then in possession of so 
many manors. " Habent Hospitalarii novemdecim millia maneri- 
orum in Christianitate," are his words. See his Histor. Angl. ad 
ann. 1244; also Du Cange, Gloss, voc. Lazari ; Mezeray, Hist 
de France. 



ELEPHANTIASIS. 3 IS 

object of their inquiry, yet it is also evident that, in con- 
sequence of the general application of the term, leprosy, 
to the Elephantiasis, to the leprosy of the Jews;* to the 
proper scaly lepra, and even to other cutaneous affec- 
tions, which have no affinity with either of the diseases 
just mentioned, almost every person, afflicted with any 
severe eruption or ulceration of the skin, was deemed 
ieprous, and was received into the la^arettoes. This 
Fact, indeed, is acknowledged by many of the physicians 
to these hospitals, in the sixteenth century and subse- 
quently. Greg. Horst, who was one of the appointed 
examiners at Ulm, towards the close of that century, 
and who has given a minute detail of his investigations^ 
admits that, " where the tubercles of the face,, the thick 

* This appears to have been the leuce of the Greeks, the white 
baras of the Arabians, and the third species of vitiligo of Celsus. 
(See Hippocrat. Tispt IL*0«v. Avicen. loc. cit. — Cels. de Med. lib. 
v. cap. 28.) The two characteristic symptoms of the Hebrew le- 
prosy, which are pointed out in the Mosaic account, are the white- 
ness of the hair of the parts affected, and the depression of the 
skin. " And if the hair of the plague is turned white, and the 
plague in sight be deefier than the skin of his flesh, it is a plague 
of leprosy, &c." (Leviticus, chap* xiii.) Thus also Avicenna: 
" There is this difference between the white alguada (alfihos) and 
the white baras; the hairs grow upon the skin affected with the 
former, and they are of a black or brown colour : but those which 
grow in the baras are always white, and at the same time the skin 
is more depressed or sunk than the rest of the surface of the body." 
(loc. cit.) And Celsus : " tevm habet quiddam simile alpho ; sed 
magis albida est, et altius descendit ; in eaque albi fiili sunt, et 
lanugini similes." 

r r 



314 TUBERCULA 

lips, acuminated ears, flattened nose, round eyes, (th* 
essential symptoms of Elephantiasis,) are absent; yet ii 
the patients are affected only with a dry and foul scabies, 
with pustular eruptions, fissures, and branny exfolia- 
tions, which constitute the psora of the Greeks, — or 
even with great itching, emaciation, ulceration, and ex- 
foliations of thicker scales, which are the lepra of the 
Greeks, — nevertheless they are sent to the lazarettoes> 
if they are poor, for the means of subsistence. Hence 
it happens/' he adds, " that, here and elsewhere, very 
few instances of real Elephantiasis are found in the la- 
zarettoes, while many are there, affected only with an 
obstinate psora or lepra Graecorum."* Forestus, wh© 
held a similar office at Alcmaer and Delft, in the same 
century, affirms that a very small proportion of the per- 
sons who wandered about the low countries, as lepers 
and beggars, were true lepers; but were merely affected 
with scabies, or some external defoedation of the skin. 
u Nay," he says, " not one in ten of them is truly a 
leper, or afflicted with the legitimate Elephantiasis."! 
Riedlin makes a similar observation respecting the pa- 
tients admitted into the leper-hospital at Vienna. J In- 

* See his Obs. Med. lib. vii. ob. xviii. epist. J. H. Hopfnero. 

f See his Obs. Chirurg. lib. iv. obs. vii. schol. 

\ " Sicuti vcro non nisi rarissime inveniuntur, quibus leprosi 
nomen merito et revera attribui posset, uti quidem leprosi a pie- 
risque auctoribus describuntur ; sed filerumque hisce domibus 
illi includuntur, qui scabie sicca, fceda, et diu jam instante, labo- 
rani, &c." D. V. Riedlin, Linnse Med. vol. iii. Ann. 1697. Mens 
Maio, 



ELEPHANTIASIS, 315 

deed there is little doubt, that every species of cachectic 
disease, accompanied with ulceration, gangrene, or any 
superficial derangement, was deemed leprous; and hence 
that, in the dark ages, when the desolation of repeated 
wars, and the imperfect state of agriculture, subjected 
Europe to almost constant scarcity of food, the nume- 
rous modifications of scurvy and ignis sacer, which were 
epidemic during periods of famine, and endemic wher- 
ever there was a local dearth, were in all probability 
classed among the varieties of leprosy; more especially 
as the last stage of the ignis sacer was marked by the 
occurrence of ulceration and gangrene of the extre- 
mities, by which the parts were mutilated, or entirely 
separated.* 

Under the head of Elephantiasis, Dr. Winterbottom 
appears to have described the leuce, and not the Ele- 
phantiasis, of the Greeks; the baras, and not the 
juzam of the Arabians. The principal symptoms 
which he witnessed, were the pale colour of the skin 
(in black subjects) and its loss of sensibility, which are 
distinctly stated as the leading symptoms of leuce, by 

* It would be foreign to my purpose to enter into any detail 
here respecting the history and symptoms of the ignis sacer, 
which was correctly ascribed by Galen (de Succor. Bonit. et Vitio, 
cap. 1. — De Natur. Humor, lib. ii. cap. 3, &c.) to the use of un- 
suitable food. It has been well described by Lucretius, lib; vi. 
In more recent times, it has been erroneously supposed to origi- 
nate from various deleterious substances taken with the food, and 
not from actual deficiency of nutriment. See above, p. 135. 



316 TUBERCULA: 

Celsus, and by the other Roman and Greek physicians, 
as well as of baras by the Arabians * Some of the 
Greeks and Arabians, indeed, seem to consider the 
leuce or baras, as possessing an affinity with Elephan- 
tiasis, and sometimes terminating in it;f and, if they be 
not modifications of the same disease, it is probable that 
some of the symptoms of the one (leuce,) such as the 
insensibility, and change of the colour and strength of 
the hair, may have been transferred in description to 
the other. The numerous large tubercles of the nose, 
forehead, and ears, which are deemed characteristic of 
Elephantiasis, did not appear in the disease seen by Dr. 
Winterbottom. The swellings or tuberosities of the 
joints of the hands and feet, which terminate in ulcera- 
tions, that occasion the fingers and toes to drop off, ap- 
pear also to belong to the two diseases in common, and 
afford another proof of their affinity. Nevertheless, as 
we have no where any account of the regular succes- 

* See Celsus de Medicina, lib. v. cap. 28. — Aetius, tetrab. iv. 
serm. i. cap. 123. — Paul. ^Eginet. lib. iv. cap. 5. — Actuarius, 
Meth. Med. lib. ii. cap. 1 1. 

t Avicenna applies the term baras, with the epithet black, to 
the rugged and scaly state of the skin in Elephantiasis : (lib. iv- 
fen. 3. tract. 3. cap. i.— and fen. 7. tract. 2. cap. 9.) and Alsahara- 
vius expressly states, that when the disease arises from putrid 
phlegm, it commences with baras, or with white bohak, (.alphos 
of the Greeks,) and becomes juzam in its advanced stage. Lib. 
Pract. tract. 31. cap. 1. See also Dr. Thomas Heberden's *count 
of Elephantiasis in the Island of Madeira, (Med. Trans, of the 
Coll, of Physicians, vol. i. p. 27.) 



ELEPHANTIASIS. 317 

sion of the tubercular state (Elephantiasis or juzam) to 
that of mere discoloration and insensibility (leuce or 
baras,) we are not warranted in drawing the conclusion, 
that they are but degrees or stages of the same disease.* 
Accurate histories of the Elephantiasis, leuce, and other 
modifications of the formidable cutaneous diseases, that 
occur in hot climates, and especially where agriculture 
and the arts of civilization are imperfectly advanced, 
must be deemed still among the desiderata of the patho- 
logist. 

By the surgeons of the present day the appellation 
of Elephantiasis is appropriated to a disease, altogether 
different from the malady originally so called by the 
Greeks; namely, to an enormously tumid condition of 
the leg, arising from a repeated effusion and collection 
of a lymphatic and gelatinous matter in the cellular 
membrane under the skin, in consequence of inflamma- 
tion of the lymphatic glands and vessels. The skin it- 

* It is curious, that the Foolas, on the coast of Africa, employ 
the Arabian terms, but, if Dr. Winterbottom was correctly in- 
formed, in an inverted sense. They divide the disease into three 
species, or rather degrees; 1. the damadyang, or mildest leucej 
when the skin is merely discoloured and insensible in patches ; 2. 
the didyam, .{sometimes written sghidam, dsjuddam, and juzam,) 
when the joints of the fingers and toes are ulcerated and drop off, 
the lips are tumid, and the alae nasi swell and ulcerate ; and 3. the 
barfas, when these symptoms are increased, and, from ulcerations 
in the throat and nose, the voice becomes hoarse and guttural. 
See his Account of the Native Africans in Sierra Leone, vol. ii. 
chap. 4. 



318 TUBERCULA. 

self is much thickened in the protracted stages of this 
extension, and its vessels become much enlarged; its 
surface grows dark, rough, and sometimes scaly* 
This condition of the surface, together with the huge 
mis-shapen figure of the limb, bearing some resem- 
blance to the leg of an elephant, suggested the applica- 
tion of the term.f As the effusion first takes place 
after a febrile paroxysm, in which the inguinal glands 
of the side about to be affected are inflamed, and the 
limb is subsequently augmented in bulk by a repetition 
of these attacks. Dr. Hendy termed the malady, " the 
glandular disease of Barbadoes," in which island it is 
endemial.J In England it is often called, " the Barba- 

* See Alibert's plate of " Lepre Elephantiasis," No. 33, where 
this is well represented. 

| The appellation of elefihant or elefihant -disease, was, in fact, 
applied to this affection by the Arabians, confessedly from this 
resemblance : (See Haly Abbas, Theor. lib. viii. cap. 18; — Aven- 
zoar, lib. ii. cap. 26 ; — Alsaharavius, Pract. tractat. xxviii. cap. 1 1, 
See.) hence the translators were puzzled, and misinterpreted ju- 
zam by the Greek term, lejira. The translator of Haly Abbas 
was alone correct in rendering the Arabic names : having given the 
proper classical appellation of Elephantiasis to the tubercular ju- 
zam, he translates this name (denoting the elephant leg) by the 
term ele/ihas. (loc. cit. : — also Theorice, lib. viii. cap. 15 ; and 
Practice, cap. 4.) For, as this disease had not been noticed by the 
Greek physicians, even by those of the Eastern empire, there was 
no classical term by which it could be rendered. 

\ See his inaugural dissertation, and subsequent treatise on the 
subject, London, 1784; also Rollo's " Remarks on the Disease 
lately described by Dr. Hendy, &c." 1785. 



Elephantiasis. 319 

does leg."* Except when these paroxysms occur, the 
functions and constitution of the patients are not 
materially injured, and they often live many years, in- 
commoded only by carrying about "such a troublesome 
load of leg."t 

In this country the disease is only seen in its inve- 
terate stage, after repeated attacks of the fever an effu- 
sion have completely altered the organization of the in- 
teguments of the limb, and rendered it altogether in- 
curable. In this state, the swelling is hard and firm, 
does not pit on pressure, and is entirely free from pain. 
The skin is thickened and much hardened; its blood- 
vessels are enlarged, particularly the external veins, and 
the lymphatics distended; and the cellular substance is 
flaccid, and sometimes thickened, and its cells much 
loaded with a gelatinous fluid. The muscles, tendons, 
ligaments, and bones, are generally in a sound state. — 

* The disease is not exclusively confined to the leg ; it some- 
times appears in the arms, and even on the ears, breasts, scrotum, 
&c. Hillary on the Diseases of Barbadoes, p. 31 3 ; — Hendy, part i. 
sect. 2. 

t See Hillary on the Climate and Dis. of Barbadoes. It is af- 
firmed by Dr. Clark, however, and by Dr. Winterbottom, that the 
agility of the patients, who are affected with this unseemly defor- 
mity, at Cochin, and on the Gold Coast, is not impaired by it. 
(See Clark's Obs. on the Dis. in long Voyages to hot Climates; 
Winterbottom, loc. cit. p. H3.) Dr. Hendy observes that, in 
consequence of the gradual augmentation of the bulk, patients 
are not in general sensible of the weight, except when they are 
debilitated by indisposition. 



320' TUBERCULA: 

In this advanced stage, the disease is altogether irreme- 
diable; and indeed little success seems to have attended 
the practice employed in the earlier stages, which has 
been chiefly directed to alleviate the febrile paroxysms 
by laxatives and diaphoretics, and subsequently to 
strengthen the system by cinchona. Local bleeding 
has never been employed; for there are no leeches in 
Barbadoes, according to Dr. Hendy; but after the fever 
and inflammation have subsided, he strongly recom- 
mends the binding of the limb in a tight bandage, as 
the means of exciting absorption, and of reducing the 
swelling.* 

* While this sheet was in the hands of the compositor, I was 
favoured by Mr. J. Mason Good, a gentleman distinguished by 
his knowledge of the oriental languages, with some observations 
relative to the original Arabic appellations of these diseases, 
which, while they confirm the views which I had entertained in 
general, throw additional light on the subject. 

" The leprosy of the Arabs," he says, " appears to have been 
called by themselves immemorially, and is still called juzam and 
juzamlyk, though vulgarly and more generally judam and judam- 
lyk, from an Arabic root, which imports erosion, truncation, ex- 
cision. The term juzam has passed from Arabia into India, and 
is the common name for the same disease, among the Cabirajas 
or Hindu physicians, who also occasionally denominate it fisadi 
khun, from its being supposed to infect the entire mass of blood, 
but more generally Ichora" 

I learn also, from this communication, that the original Arabic 
term, which was used to denote the tumid leg, above mentioned, 
was daljil, which is literally elephant disease ; and further, that 
" dal fil is the common name for the swelled leg in the present day 



ELEPHANTIASIS. 321 

In conclusion, then, it will be seen that the terms 
Elephantiasis and lepra have been thus confounded. 
The word lepra (which should be confined to a scaly 
disease) has been erroneously applied to the proper 
Elephantiasis (a tubercular disease.) Elephantiasis again, 
which is so distinctly described by the Greek writers, 
has been transferred, by the Latin translators of the Ara- 

among the Arabians, who sometimes contract it to Jil alone, lite- 
rally elefi/tas. v 

But although the Arabians in general distinguished the juzam 
from other diseases ; yet I have observed, that they sometimes 
mentioned the baras {leuce) as having an affinity with it, calling 
some forms of the juzam black baras. Mr. Good remarks, that 
" juzam itself has occasionally been employed in the same loose 
manner, and has been made to import leuce or vitiligo, as well as- 
proper or black judam ; though in the former case it is commonly 
distinguished by the epithet merd, i. e. fiilis carens, as merd-juzam t 
bald-juzam. The proper and more usual name for this last diseasej 
is beras oraberas, sometimes written alberas, though less correctly, 
as this last is beras with a mere prefix of the definite article." 

Mr. Good adds, " that one of the most celebrated remedies for 
this disease (juzam) employed by the Cabirajas, or Hindu physi- 
cians, is arsenic (Shuce, in India sane' hya) mixed in pills with 
black pepper," six parts of the latter being added to one of the 
former : the pills are ordered to be of the size of small pulse, and 
one of them is to be swallowed morning and evening, with some 
betel leaf. 

Since the publication of the former editions, I have had an oppor- 
tunity of seeing two cases of Elephantiasis, which have been under 
treatment in London during the greater part of the present year 
(1814;) and in both, the arsenic had been fully tried, and proved 
to be entirely void of any remedial power, 
SS 



iU TUBERCULA: 

bian writers, to the local affection of the leg, (the elephas 
of these writers, the Barbadoes leg, and the glandular 
disease of Dr. Hendy,) and is commonly used in that ac- 
ceptation by practitioners at present. But it has been 
also misapplied to the white disease of the skin, called by 
the Greeks, Romans, and Arabians, leuce, vitiligo, and 
baras (or beras) respectively; and thence, by an easy 
step, it has been again transferred, by some unlearned 
persons, even to the scaly lepra; while the term lepra has 
been often indiscriminately applied to all these affections. 
I trust the foregoing statements may contribute to eluci- 
date this matter, 



IX. FRAMBCESIA. 
YAWS. 

The nature of this disease, which is indigenous in 
Africa, and has been thence conveyed to the West In- 
dies and America, has been imperfectly investigated by 
European practitioners; and as it is perhaps never seen 
in England, a very brief account of it here will be suf- 
ficient* 

*M. Aliberthas figured two diseases as examples of Framboesia, 
under the titles of " pian ruboide," and " P. fungoide," which were 
seen at the hospital St. Louis at Paris ; but they are obviously not 
Yaws. The first of them appears to be a neglected porrigo, or a 
sycosis, of the scalp (plate 35 ;) and the other a species of v CI> 
(plate 36.) 



.FRAMBGGSIA. 32B 

The eruption of the Yaws sometimes commences 
without any precursory symptoms of ill health; but it 
is generally preceded by a slight febrile state, with lan- 
guor, debility, and pains of the joints, resembling those 
of rheumatism.* After several days, minute protu- 
berances! appear on various parts of the skin, at first 
smaller than the head of a pin, but gradually enlarging, 
in some cases to the diameter of a sixpence, and in 

* The earlier writers on this disease assert, that the general health 
is not impaired by this eruption during the first stages. But on the 
authority of Dr.- Winterbottom, and of Dr. Dancer, I have stated 
that zfebricula is the ordinary precursor of the Yaws. Dr. Winter- 
bottom, indeed, observes that the successive eruptions, which occur, 
are also usually preceded by slight febrile paroxysms, sometimes 
by rigors. See his Account of the Nat. Africans of Sierra Leone, 
vol. ii. chap. 8 ; — and Dancer's Medical Assistant. 

f It is not easy to discover the precise character of this eruption, 
from the varying language of authors. An anonymous writer, who 
gave the first explicit account of the disease, (see Edin. Med. Es- 
says, vol. v. part ii. art. 76.) says they are at first " level or smooth 
with the skin," but soon " become protuberant like pimples" Dr. 
Hillary, ;who has copied much from this writer, describes them as 
" pimples" though smooth and level with the skin, but soon be- 
coming" protuberant/zMsta/es." (On the Dis. of Barbadoes, p. 339.) 
And Dr. Winterbottom, who has given, on the whole, the most per- 
spicuous description of the disease, calls them '■'■pustules" from 
their first appearance. Again, as to the contents of these eruptions, 
the anonymous author and Dr. Hillary say that no pus, nor any 
quantity of ichor is found in them, but speak of a little ichor as 
drying upon the surface; while Dr. Winterbottom says, they are 
" filled with an opake whitish fluid," and when they burst," a thick 
viscid matter is discharged." 



SS4 TUBERCtJLA: 

others even to a greater extent: they are most numer- 
ous, and of the largest size, in the face, groins, axilla?, 
and about the anus and pudenda. But the crop is not 
Completed at once; new eruptions appear in different 
places, while some of the earlier ones dry off. When 
the cuticle is broken, a foul crust is formed on the 
surface, from under which, on the larger protuberances, 
red fungous excrescences often spring up, which attain 
different magnitudes, from that of a small raspberry 
to that of a large mulberry, which fruit they some- 
what resemble from their granulated surfaces.* When 
the eruption is most copious, these tubercles are of the 
smallest size; and when fewer, they are largest. Their 
duration and progress are various in different constitu- 
tions, and at different periods of life. Children suffer 
less severely than adults, and are more speedily freed 
from the disease: in them, according to Dr. Winter- 
bottom, the duration of the Yaws is from six to nine 
months; while, in adults, it is seldom cured in less 
than a year, and sometimes continues during two or 
three. The fungous tubercles attain their acme, ac- 
cording to the anonymous writer already quoted, more 
rapidly in the well-fed negroes, than in those wl 
ill-fed and thin; and they likewise acquire a larger 
size in the former than in the latter. They are not 

* Hence both the popular appellation of Yaw, which in some 
African dialect signifies a raspberry, and the nosological title Fram- 
basia, from the French Framboise, which denotes the same fruit. 
See Sauvages, Nosol. JMeth. class, x. ord. vr. gen. 23. 



PRAMBGESIA. S'25 

possessed of much sensibility, and are not the seat of 
any pain, except when they appear upon the soles of 
the feet, where they are confined and compressed by 
the hard and thickened cuticle: in that situation they 
render the act of walking extremely painful, or alto- 
gether impracticable. They never suppurate kindly, Dr. 
Winterbottom says, but gradually discharge a sordid glu- 
tinous fluid, which forms an ugly scab round the edges 
of the excrescence, and covers the upper part of it, when 
much elevated, with white sloughs. When they appear 
on any part of the body covered with hair, this gradually 
changes in its colour from black to white, independently 
of the white incrustation from the discharge. They 
leave no depression of the skin* 

* The anonymous writer in the Edin. Med. Essays, and after 
him Dr. Hillary, and others, have deemed the Framboesia to be the 
Hebrew leprosy, described by Moses. (Leviticus, chap, xiii.) In 
some respects, and especially in the appearance of what is called 
"raw flesh," in the leprous spots, together with whiteness of the 
hair, the description of the leprosy of the Jews is applicable to the 
Yaws. But the leprosy is described by the great legislator as be- 
ginning in several ways, or appearing under several varieties of 
form, in only one of which this rising of " raw flesh" is mentioned : 
and the two circumstances, which all these varieties exhibited in 
common, were a depression of the skin, and whiteness of the hair. 
Now this change in the colour of the hair is common to the Fram- 
boesia, and to the leuce, as stated ; and it is conjoined, in the lat- 
ter, with cutaneous depression. It seems pretty obvious, indeed, 
that the term leprosy was used, in the Scriptures, to denote seve- 
ral diseases of the skin, against which the law of exclusion wa? 



326 TUBERCULA: 

The period during which the eruption is in progress, 
varies from a few weeks to several months. " When 
no more pustules are thrown out" Dr. Winterbottom 
observes, " and when those already upon the skin no 
longer increase in size, the diseased is supposed to have 
reached its acme. About this time it happens, on some 
part of the body or other, that one of the pustules be- 
comes much larger than the rest, equalling or surpassing 
the size of a half-crown piece: it assumes the appear- 
ance of an ulcer, and, instead of being elevated above 
the skin like others, it is considerably depressed; the 
surface is foul and sloughy, and pours out an ill-condi- 
tioned ichor, which spreads very much, by corroding the 
surrounding sound skin: this is what is called the mas- 
ter, or mother-yaw." When arrived at its acme, how- 
ever, the eruption continues a considerable time without 
undergoing much alteration, often without very mate- 
rially injuring the functions, and it seldom proves dan- 
gerous, except from the mischievous interference of ill- 
directed art.* 

The Frambcesia is propagated solely by the contagion 

enforced, and others, to which it did not apply. An instance of the 
latter occurs in Gehazi. whom we find still in the employment of 
Elisha, and even conversing with the king, after the leprosy had 
been inflicted upon him, "and his seed for ever." (2 Kings, chap. 
v. and vi. and chap. viii. ver. 4.) 

* " All this time the patient is in goo i health, does not lose his 
appetite, and seems to have no other uneasiness, hut what the nas- 
tiness of the sons <>cca- ons, &c." Edin. Med. Essays, vol. v. p. 
"89. The fact is stated by Hillary in the same words, p. 343. 



FRAMB(ESIA. 327v 

of the matter, discharged from the eruption, when it is 
applied to the wounded or broken skin of another per- 
son, who has not previously undergone the disease.* 
For, like the febrile eruptions, the Framboesia affects 
the same person only once during life; but, unlike them., 
it is not propagated by effluvia. In Africa it is usually 
undergone during childhood. The period which elapses 
between the reception of the contagion and the com- 
mencement of the disease, is no where mentioned: but 
in the case of a Dane, whom Dr. Adams saw at Madei- 
ra, the patient had been ten months absent from the 
West Indies, before he felt any indisposition.f 

With respect to the treatment of Framboesia, nothing 
very satisfactory is to be collected from the writings of 
the practitioners to whom we are indebted for the his- 
tory of the disease. The native Africans, according to 
Dr. Winterbottom, "never attempt to cure it, until it 
has nearly reached its height, when the fungi have ac- 
quired their full size, and no more pustules appear/' 
And the practitioners in the West Indies soon learned, 
by experience, that active evacuations retard the natural 

* The complaint is sometimes inoculated by flies, in those hot 
countries, where the skin both of the diseased and the healthy re- 
mains uncovered. Hence, Dr. Bancroft says, " none ever receive 
it whose skins are whole ; for which reason the whites are rarely 
infected ; but the backs of the negroes being often raw by whip- 
ping, and suffered to remain naked, they scarce ever escape it." 
Nat. Hist, of Guiana, p. 385. See also Winterbottom, pp. 141—3. 

t See Memoirs of the Med. Soc. of London. 



328 ( TUBERCULA: 

progress of the disease; and that mercurials, although 
they suspended it, and cleared the skin of the eruption, 
yet left the patient still susceptible of, or rather still im- 
pregnated with, the virus, which speedily evinced its 
presence, by a reappearance of the symptoms more se- 
vere and tedious than before. In truth, the disease, it 
would seem, like the pustular and exanthematous fevers 
of our own climate, will only leave the constitution, after 
it has completed the various stages of its course, and 
removed the susceptibility of the individual to future 
infection; and no medicine, yet discovered, has had any 
influence in superseding this action, or in accelerating 
its progress. Unless, therefore, any urgent symptoms 
should require alleviation, (which seldom, if ever, hap- 
pens,) it is advisable to dispense with the administration 
of medicine, and to be content with restricting the pa- 
tient to a moderate and temperate regimen, during the 
first stage of the malady. When the eruptions begin to 
dry, or as soon as they cease to multiply and enlarge, 
the disease appears to require the same management as 
other slow and superficial ulcerations, accompanied with 
a cachectic state of the system; viz. a light, but nutri- 
tious diet, a dry and wholesome air, warm clothing, mo- 
derate exercise, and a course of tonic medicine, espe- 
cially of sarsaparilla, or cinchona, with the mineral 
acids, or with antimonials and small doses of mercury, 
according to the circumstances of the individual habit. 
The effects of mercury, however, exhibited so as to 



i 



TRAMBGESIA. 329 

«xcite salivation,* as the early West Indian practitioners 
recommend, seem to be of a very questionable nature, 
especially when it is unaccompanied by the vegetable 
decoctions; and it is certain that patients have, in some 
cases, soon recovered under the use of the latter, whei 
the mercurials were omittecLf The native Africans 
employ decoctions of the bark of two or three trees, 
which are gently purgative, as well as tonic, and like- 
wise wash the sores with them, after carefully removing 
the crusts. J 

The master-yaw sometimes remains large and trou- 

* This treatment is often followed by a train of harassing symp- 
toms, called by the negroes, the bone-ache. " The unhappy suf- 
ferer is tormented with deep-seated pains in the bones, especially 
round the joints, which are occasionally aggravated to a violent 
degree : the periosteum becomes thickened, inflamed, and pain- 
ful, and nodes are formed on the bones. When these symptoms 
have continued for some time, the bones are affected with caries, 
and even become soft and lose their form." 

t See Dr. Winterbottom's "Account, fee." ii. p. 158-9; and 
Schilling, de Framboesia, quoted by him. 

| In a very short but able account of this disease, which I lately 
saw in MS., the mercurial treatment was said not only to be un- 
successful, but to aggravate the affection of the skin ; and much 
advantage was ascribed to strong decoctions of the woods, of ver- 
vain, wild senna, fee, when the scabs began to fall off; and to the 
frequent ablution of the diseased parts with warm water, and to the 
use of lime-water as a drink previously. These decoctions were 
also found to relieve " the small eruption, bone-ache, and joint- 
evil often consequent on the bad treatment, or mere palliation," bj 
mercury. 



330 TUBERCULA. 

blesome, after the rest of the eruption has altogether 
disappeared. It requires to be treated with gentle 
escharotics, and soon assumes a healing appearance 
under these applications. Stronger caustics are requi- 
site for the cure of the crab-yaws, or tedious excres- 
cences, which occur on the soles of the feet. 



pi 

Oider VIIL 

MACULE. 

This order comprises those discolorations of the skin 
which are permanent, and most of which are the result 
of an alteration of the natural texture of the part. It 
comprehends, therefore, several varieties of connate and 
acquired disfigurations of the skin, some of which are 
not capable of being removed, and most of them are 
removable only by surgical means; The various Ma- 
culae, that have been described in medical and surgical 
writings, are included under the terms Ephelis, "Nm- 
vus, Spilus, and moles, with other appellations applied 
to the more anomalous appearances. 



I. EPHELIS. 

The term Ephelis (Plate LXIX.) denotes not only 
the freckles, or little yellow lentigines, which appear on 
persons of fair skin, and the larger brown patches, 
which likewise arise from exposure to the direct rays 
of the sun, as the name imports; but also those large 
dusky patches, which are very similar in appearance^ 
but occur on other parts of the surface, which are con* 
stantly covered.* Lorry and some other writers have 

* « Nomen inditum ano rx tiXm, non quod a sole tantum vitia 
ilia in cute contrahuntur, sed quod a reliquiisinducta causis, simi* 



33£ MACULE; 

endeavoured to make distinctions between lentigines and 
Ephelides; but there does not appear to be any essential 
difference between them, and all the ancient writers 
have properly treated of them together.* 

The larger Ephelides, especially those which occur 
on /the sides, abdomen, and other covered parts, some- 
times differ little from the pityriasis versicolor, or actu- 
ally degenerate into it; the cuticle becoming rough with 
minute furfuraceous scales. The brief description of 
the Ephelis given by Celsus is, indeed, equally applica- 
ble to both. " Nihil est nisi asperitas quaedem, et duri- 
ties, mali coloris.' , f I have occasionally known the dingy 

lem aspcritatem et colorem habeant." Gorraei Defin. ad voc. epyAiw 
— This acceptation of the term is sanctioned by the authority of 
Hippocrates, who gives the same appellation to the spots, which 
sometimes occur in pregnant women, and to those occasioned by 
the solar rays. "Quae utero gerunt in facie maculam habent, 
quam tQnXn vocant." — Lib. Hipi ex/popuv. Also Uepi ywxtxetw, 
lib. ii. Sauvages lias improperly classed with Ephelis the mottled 
and dusky red hue of the shins of those, who expose their legs 
constantly to strong fires in the winter ; and also the livid patches 
of scurvy, which arise from extravasation of blood under the cu- 
licle. Nosol. Meth. class, i. gen. iii. spec. 4 & 6. — See also Plenck 
de Morb. Cut, class, i. spec. 2. : and Plater has, by an extraordi- 
nary mistake, called the pustules of scabies, Ephelides. De Su~ 
perfic. Corp. Dolore, cap. 17. 

* See Oribas. de Loc. Affect. Cur. lib. iv. cap. 52, and SynoDS. 
viii. 33. — Aetius, tetr. ii. serm. iv. cap. 11. — Actuar. Meth. Med. 
iv. cap. 13. 

t De Medicina, lib. vi. cap. 5. — M. Alibert has thought the 
common freckle and the larger Ephelis worthy of two beautiful 



EPHELIS. 3#> 

hue of these maculae, as well as of the patches of pity- 
riasis, give rise to a suspicion of syphilitic infection. But 
independently of the history of the previous symptoms, 
the paucity of these patches, their want of elevation or 
depression, their permanency, and their final evanes- 
cence, without any tendency to ulceration, or even to in- 
flammation, will enable those, whom a habit of inspect- 
ing such appearances has not sufficiently instructed, to 
discriminate them. 

Celsus apologizes, as has been already observed, for 
prescribing the treatment of Ephelides and freckles, and 
such trifling discolorations of the skin; and the same 
apology must still be urged: "eripi tamen foeminis cura 
cultus sui non potest." The uniform practice both of 
ancient and modern authors has been to apply some 
gentle astringent and discutient lotion or liniment to the 
parts affected.* From the time of Hippocrates, bitter 
almonds have been recommended as possessed of such 
discutient properties.! They have probably no active 
virtues, which are not possessed by the ptisan, decoc- 

engravings ; the former, in plate 26, is called " Ephelide lend- 
forme," and the latter, in plate 27, " Ephelide hepatique." 

* In the remedies adapted to all these superficial and cuticular 
discolorationsj according to Oribasius, " mediocri adstrictione et 
abstersione opus est." Synops. lib. viii. cap. 33. The same ob- 
servation is stated from Crito, by Aetius, tetr. ii. serm.iv. cap. 11. 
See also Actuarius, Meth. Med. lib. iv. cap. 13. 

t Hippo, nipt yvvctiKttM, lib. ii. Oribasius says, " Amygdalae 
amarae suntfacultatisperspicueattenuantis, ut ephelin expurgent." 
De Virtute Simplic. lib. ii. cap. i. 



334 MACULjE: 

tions of tares, and some other mucilaginous and deter- 
gent applications, recommended by the same authors. 
Some gentle restringent or stimulant is commonly ad- 
vised, however, by these writers. Celsus employed re- 
sin, with a third part of fossil salt, and a little honey; — 
and Actuarius combined vinegar, honey, and bitter al- 
monds for the same purpose.- Wine was likewise re- 
commended as a vehicle for these and other substances. 
The principle of these applications was correct; but 
it may be pursued in a more simple and effectual man- 
ner by lotions of alcohol, in its pure state, or diluted with 
some distilled water, if the skin be irritable; — by dab- 
bing the spots two or three times a day with the diluted 
mineral acids, in the proportion of about a drachm of 
the strong sulphuric acid to a pint of water, or the same 
quantity of muriatic acid to half a pint; — or by using, in 
a similar manner, the liquor potassae diluted with about 
twenty times its quantity of water. 



II. N^VUS, ETC. 

The various congenital excrescences and discolora- 
tions of the skin, to which the appellations of Naevusf 

* Celsus, loc. cit. — Actuarius, loc. cit. — Dr. Withering recom- 
mends an infusion of horse-radish in milk, as a cosmetic. See his 
Botan. Arrang. of Brit. Plants. Of these cosmetic lotions, how* 
ever, we may say, with Celsus, " pene ineptiae sunt." 

t In consequence of the old notion, that these spots were im- 
pressed upon the foetus by the emotions of the mother, the term 






NAEVUS, ETC. 335 

spilus, moles, &c. have been applied, may be conveni- 
ently treated of together. They exhibit many peculiari- 
ties of form, magnitude, colour, and structure, and 
are seen on almost every part of the surface of the body 
in different instances. Some of them are merely super- 
ficial, or stain-like spots, and appear to consist of a par- 
tial thickening of the rete mucosum, sometimes of a yel- 
low or yellowish brown, sometimes of a blueish, livid, or 
nearly black colour. To these the term Spilus* has 
been more particularly appropriated. Others again ex- 
hibit various degrees of thickening, elevation, and altered 
structure of the skin itselff, and consist of clusters of en- 
larged and contorted veins, freely anastomosing, and 
forming little sacs of blood. These are sometimes spread 
more or less extensively over the surface, occasionally 
covering even the whole of an extremity, or one half of 
the trunk of the body; and sometimes they are elevated 
into prominences of various form and magnitude. Oc- 

Naevus is commonly associated with the epithet maternus, and the 
appellations of mutter-mahly mother -sfiots, fancy -marks, Sec, have 
been given to them in different languages. See Turner on Dis- 
eases of the Skin, chap. xii. 

* 2»-<A«5, macula. This discoloration seems to be included by 
Sauvages under his first species, Naevus sigillum, and by Plenck, 
under N. lenticularis, spec. i. of his Arrangement. See Sauvages, 
Nos. Meth. class. 1. gen. 4.; Plenck, Doctrina de Morb. Cutan. 
p. 37. 

t Sauvages comprehends all these excrescences under Naevus 
maternus, spec. 2; and Plenck under his four remaining species, 
Itf.Jlammeus, tuberculosus, cavemosus, and malignus.. 



333 MACULE: 

casionally these marks are nearly of the usual colour oi 
the skin; but most commonly they are of a purplish red 
colour, of varying degrees of intensity, such as the pre- 
sence of a considerable collection of blood-vessels, situ- 
ated near the surface, and covered with a thin cuticle, 
naturally occasions. 

The origin, which was anciently assigned to these 
marks by physicians, and to which they are still ascribed 
by the vulgar, (viz. the influence of the imagination of 
the mother upon the child in utero,) has occasioned 
their varieties to be compared with the different objects 
of desire or aversion, which were supposed to operate 
on the passions of the mother: whence the following 
Nasvi have been described. The flat and purple stains 
were considered as the representative of claret, or of port 
wine (Plate LXXI. Fig. 1. ;) and sometimes of a slice 
of bacon, or other flesh. Sometimes the stains are 
regularly formed, like a leaf, with a very red border, 
and lines, like veins, across from a central rib, forming 
the Naevus foliacem (Plate LXX. Fig. 1. :) and some- 
times a small red centre with branching lines, like legs, 
has suggested the idea of a spider, or N. araneiis* 
(Plate LXXI. Fig. 2.) But those Nsevi which are pro- 
minent have most commonly been compared to different 
species of fruity especially to cherries, currants, and 
grapes, when the surface is smooth and polished ; or to 
mulberries, raspberries, and strawberries, when the sur- 

* See the Plate, fig. 8.x. 



N.&VUS, ETC. 337 

face is granulated: whence the Nasvus cerams, (Plate 
LXX. Fig. 2.) ribes, morus, rubus, fragarius, &c* 
(Plate LXXII.) 

Some of these excrescences are raised upon a neck 
or pedicle; while some are sessile upon a broad base. 
Some of them again, although vivid for some time after 
birth, gradually fade and disappear; some remain sta- 
tionary through life, but commonly vary in intensity of 
colour at different seasons and under circumstances 
easily explained: and others begin to grow and extend, 
sometimes immediately after birth, and sometimes from 
incidental causes, at a subsequent period, and from 
small beginnings become large and formidable bloody 
tumours, readily bursting, and pouring out impetuous 
and alarming haemorrhages, which, if they do not 
prove suddenly fatal, materially injure the health by 
the frequent depletion of the system. Sometimes, how- 
ever, after having increased to a certain degree, they 
cease to enlarge, and thenceforth continue stationary, or 
gradually diminish, till scarcely any vestige remains.f 

In some instances, however, these preternatural en- 
largements and anastomoses, which constitute the Na3vi, 
are not merely cutaneous. A similar morbid structure 
may take place in other parts; it sometimes occupies 

* See Bierling Adversaria Curios, obs. ix. — Valentin. Prax* 
Med. Infallib. cap. 1. — Strobelberger de Curand. pueril. Affect. 
cap. 17. — Septalius de Naevis. 

t See Mr. Abernethy's Surgical Works, vol. ii. p„ 224 et seq* 

u u 



338 MACULAE 

the whole substance of the cheek, according to Mr. 
Abernethy, and has occurred in the orbit of the eye; 
and Mr. John Bell affirms, that it affects indifferently all 
parts of the body, even the viscera.* 

The origin of these connate deformities is equally 
inexplicable with that of other anomalous and mon- 
strous productions of nature; but it would be insulting 
the understanding of the reader, to waste one word in 
refutation of the vulgar hypothesis, which ascribes them 
to the mental emotions of the mother, — an hypothesis 
totally irreconcilable with the established principles of 
physiology, and with the demonstrable nature of the 
connection between the foetus and the parent, as well as 
with all sober observation. 

It is important, however, to know, that very slight 
causes of irritation, such as a trifling bruise, or a tight 
hat, will sometimes excite a mere stain-like speck, or a 
minute livid tubercle, into that diseased action, which 
occasions its growth. This growth is carried on by a 
kind of inflammatory action of the surrounding arteries; 
and the varying intensity of colour arises from the dif- 

* The ordinary Naevi appear to consist of venous anastomoses 
only : but some of them, even when congenital, are of that spe- 
cies of morbid structure, which Mr. John Bell has denominated 
" aneurism by anastomosis," and which, he says, is made up of " a 
congeries of small and active arteries, absorbing veins, and in- 
termediate cells," somewhat analogous to the structure of the 
placenta, or of the gills of a turkey-cock. See his Principles of 
Surgery, vol. i. discourse xi. ; also Mr. Abernethy's Surg. Works, 
loc. cit. 



NjEvus, etc. 339 

ferent degrees of activity in the circulation. Thus 
these marks are of a more vivid red in the spring 
and summer, not in sympathy with the ripening fruit, 
but from the more copious determination of blood to the 
skin, in consequence of the increase of the atmospheric 
temperature. The same increased determination to 
the surface is also produced temporarily, and, with it, 
a temporary augmentation of the florid colour of the 
Nsevi, by other causes of excitement to the circulation; 
as by active exercise, by heated rooms, or the warmth 
of the bed, by drinking strong liquors, or high feeding, 
by emotions of the mind, and, in women, by the 
erethism of menstruation. 

These considerations will serve to suggest the proper 
means of treating the Naevi and spili, where any treat- 
ment is advisable. When they are merely superficial, 
without elevation, which would render them liable to 
accidental rupture, and without any tendency to enlarge 
and spread, there appears to be no good reason for in- 
terfering with them. The applications mentioned by 
the older writers, were doubtless as futile as they were 
disgusting; such as saliva, the meconium of infants, 
the lochial blood of women, the hand of a corpse, &c. : 
and the severe resource of the knife, even if the de- 
formity of a scar were much less than that of the ori- 
ginal mark, is scarcely to be recommended. 

But when the Nsevi evince a tendency to enlarge, or 
are very prominent excrescences, and either trouble- 



iJ40 MACULAE. 

some from their situation,* or liable to be ruptured, 
some active treatment will then be required. Either 
their growth must be repressed by sedative applications, 
or the whole morbid congeries of vessels must be ex- 
tirpated by the knife. 

All strong stimulants externally must be avoided, as 
they are liable to produce severe inflammation, and 
even constitutional disorder. 

The consideration of the mode in which these vas- 
cular excrescences grow, by a degree of inflammatory 
action in the surrounding vessels, suggested to Mr 
Abernethy the propriety of maintaining a constant seda- 
tive influence upon those vessels, by the steady applica- 
tion of cold, by means of folded linen kept constantly 
wet. This practice has succeeded, in several instances, 
in repressing the growth of these unnatural structures., 
which have afterwards shrunk, and disappeared, or 
ceased to be objects of any importance. Pressure may, 
in some instances, be combined with this sedative appli- 
cation, and contribute to diminish the dilatation of the 
vessels: but in the majority of cases, pressure is the 
source of great irritation to these macular, and cannot 
be employed. The temporary enlargement of these 
prominent Nsevi by every species of general excitement, 
would teach us to enjoin moderation in diet, exercise, 
&,c. during the attempts to subdue them. 

* A cherry -navus on the lip, for instance, has prevented the 
act of sucking. 



NJEVUS, EtC. 341 

The mode of extirpation is within the province of the 
surgeon; and the proper choice of the mode, under the 
different circumstances, is directed in surgical books. 
From the days of Fabricius Hildanus,* the propriety of 
radically removing every part of the diseased tissue of 
vessels has been inculcated: but Mr. John Bell has most 
satisfactorily stated the grounds of that precept, by ex- 
plaining the structure of these excrescences, as well as 
the source of the failure and danger, when they are only 
cut into, or opened by caustic. I shall therefore refer 
the reader to his " Discourse," already quoted. 

The varieties of spilus, or mere thickening and dis- 
coloration of the rete mucosum, are sometimes remov- 
able by stimulant and restringent applications. A com- 
bination of lime and soap is extolled by several writers: 
and lotions of strong spirit, with the liquor potassse, as 
recommended for the treatment of the ephelides and 
of pityriasis, certainly sometimes remove these maculas. 

With respect to those brown maculas, commonly call- 
ed moles, I have little to observe: for no advantage is 
obtained by any kind of treatment. It is scarcely safe ? 
indeed, to interfere with them: for when suppuration is 
induced in them, it is always tedious and painful, the 
matter emitting at the commencement an extremely fetid 
odour. When moles are irritated by accident, or rudely 
treated, so as to produce excoriation, they are liable, it 
is said, to become gangrenous, and thus to produce sud- 
den fatality. 

* Fab. Hild. Oper. cent. v. obs. 46. 



342 MACULE. 

Moles are not always congenital. I lately saw an 
instance in a lady of remarkably fair and delicate skin, 
where a numerous crop of small moles appeared, in 
slow succession, upon the arms and neck. Congenital 
moles, indeed, are not always stationary; but they some- 
times enlarge, gradually, for a time, and afterwards dis- 
appear. 



THE END 



INDEX. 



Page. 

Acarus scabiei - 206 

Achores - - - - - - I63 

Acne ------- 284 

— — simplex - - - - - 285 

punctata - - - - - 291 

indurata - - - - - 292 

« rosacea ------ 297 

Albaras - - - - - - 31 

Albohak ------- id. 

Alopecia - - - - - - 178 

Alphos ------ 30. 282 

Aphtha .-.--. 268 

lactantium ----- 269 

adultorum ----- 274 

anginosa ----- 276 

Area ------ 178 

Baras. See Elephantiasis. 

Blister, followed by Eczema - -' - 262 

Bullae - - - - - - - 126 

Chicken-pox - - - - - 212 

lenticular - - - - - 214 

• conoidal - - - - 215 

— — globated - - - - 216 

Courap - - - - - - 150 

Cow-pox. See Vaccinia. 

Crusta lactea. See Porrigo larvalis. 

Crystalli. See Chicken-pox. 

Dandriff. See Pityriasis. 

Ecthyma ------ 135 

vulgare - - - - - 187 

infantile - - - - - 188 

■ luridum - -" - - - ibid. 

— — cachecticum ----- 190 

Eczema ------ 257 

-solare ------ 258 

impetiginodes - - - - 261 

rubrum ----- 263 

—. — __- from mercury - - - 264 



344 INDEX 

Page. 
Elephantiasis ------ 306 

EpheJis 331 

Epinyclis 96.278 

Ergot - ..... 136 

Erysipelas - - - - - - 127 

. phlegmonodes ... - 

oedematodes ----- 129 

130 

132 

of infants - - - - 131 



gangrsenosum 
. erraticum 



Erythema 

— — fugax 



- 119 

121 

lave ------ ib. 

, marginatum - 

papulatum ----- ibid. 

tuberculatum - 

. nodosum ----- ibid. 

Exanthema, what ----- 56 

Favus 163 

Febris ampullosa. See Pemphigus. 

bullosa. See the same. 

— vesicularis. See the same. 

Fevers, eruptive, known to the ancients ... 64 

Fici. See Sycosis. 

Fish-skin Disease. See Ichthyosis. 

Formica. See Herpes. 

Framboesia - - 322 

Freckle. See Ephelis. 

Furunculus ------ 278 

Gum, red. See Strophulus. 

Gutta rosea. See Acne rosacea. 

Haemorrhoea petechialis. S< Purpura. 

Heat, , See Lichen tropicus. 

Herodotus, described febrile eruj uons - - - 66 

Herpes ... 227 

phlyctsencdes ... - '230 

■ zoster 

circinatus .... 38 

. labialia ..... I 

praeputialis - 

. Iris ------ 

Hives. See Chicken-pox. 

Horns, nature and origin of - - - II 

II . Jrargyria. See Eczema rubrum. 

Ich hyosis ------ 49 

simplex - - 50 

cornea - 53 

Jjrnis sacer - - - - - 136. 315 



INDEX. 3 4 5 

Page. 

Ignis Sancti Anthonii - - - - 136 

Impetigo - - - - - . us 

figurata ----- ibid. 

sparsa - - - - - 152 

■ erysipelatodes - - - - 158 

scabida - - - - . - 1 60 

rodens - - - - 161 



Intertrigo - - - - - 124 

Ionthos. See Acne. 

Iris. See Herpes Iris. 

Itch. See Scabies. 

Itch, Baker's .-.„.._ 41 

——Grocer's ..... 154.262 

Bricklayer's .... n,^. ibid. 

Itch insect ...... 205 

Judam. See Elephantiasis. 

Juzam. See the same. 

Kriebel Krankheit - - - -' - 136 

Lactucimen. See Aphtha. 

Larvae mistaken for pediculi - - - 21 

Lentigo. See Ephelis. 

Lepra ...... 2 5 

vulgaris - - - - - - 26 

alphoides ..... 30 

— — — nigricans - - - - - - 36 

Arabum, a mistake .... 35 

Leprosy of the middle ages - - - - 312 

Leuce, probably the Jewish Leprosy * - 31 

differs from Lepra ... 30, 282 

Lice - - - n - - - . 21 

Lichen ------- 5 

simplex ..... 7 

pilaris g 

circumscriptus .... n,^ 

— agrius ------ 10 

lividus - - - - . 12 

tropicus - - - - . - 13 

. urticatus ..... n,^ 

Lupus - - - - - ... 304 

Maculae . - - • - - - - 331 

• hepaticse - - - - - 48 

Ma J des Ardens - - - - - 135 

Measles - .. - - - - 57 

antiquity of - - - - - - 65 

Mercurial rash. See Eczema. 

Miliaria - - - - - - 249 

X X 



346 INDEX. 

Page. 

Molluscum _----- 279 

Morbilli. See Rubeola. 

Morphaea - - - - - -26.31 

Mother-spots. See Nsevus. 

Muscles, rash produced by eating - - - 9 1 

Naevus _..--- 334 

Necrosis - - - - - - 156 

Nettle-rash. See Urticaria. 

from eating shell-fish, &c. - - 91 

Nirles. See Herpes phlyctaenodes. 

Noli me tangere. See Lupus. 

Ophiasis - - - - - - 1 78 

Papulae ------- l 

Pemphigus - - - - - - 138 

v . probably no such disease - - - ibid. 

Petechias sine febre. See Purpura. 

Phlyzacia - - - - - - 185 

Phyma ------- 278 

Pimples. See Papulae. 

Pitch, internally - - - - - 34. 52 

Pityx'iasis ------ 45 

. capitis ----- ibid. 

. rubra ------ 46 

. versicolor - ... ibid. 

nigra - - 49 

Pompholyx - - - - - - 142 

— . — . ■ benignus - - ibid. 

. diutinus ----- ibid. 

• solitarius - - - - - 145 

Porrigo - - - - - - 162 

larvalis - - - - - - 163 

. furfurans - - - - - 167 

■ lupinosa ... - - 169 

scutulata - - - - - 171 

- decalvans - - - - - 177 

. favosa - - - - - 179 

Prurigo -------14 

mitis - - - - - 15 

formicans - - - - - 16 

senilis ..... 19 

local varieties of ... 22. 24 

Psora. See Psoriasis. 

. erroneously applied to Scabies - - - 194 

Psoriasis ..---- 36 

guttata - - - - - 39 

diffusa ----- ibid. 

gyrata - - - 41 



INDEX. 347 

Page. 
Psoriasis inveterata - - - - - 41 

local varieties - _ _ . 42 

Psydracia - - - - - -148 

Purpura - - - - - - 104 

simplex - - - - - -106 

hemorrhagica - - - - ibid. 

- — urticans - ■ - - - - 117 

senilis - - - - - 118 

— contagiosa - . - - - - 119 

Pustules ...... i4f 

- — four varieties of - - - _ X xi 

Rashes - - - - - - 56 

Ringworm, various - - . , - 150.155.238 

of the Scalp. See Porrigo scutulata. 

Roseola ...... 97 

— sestiva - .... _ 98 

autumnalis ----- 99 

— annulata - ibid. 

infantilis - - - - - - 100 

variolosa - 101 

vaccina - - - - - - 102 

miliaris - - - - - 103 

Rubeola -- - - - - -57 

vulgaris - - - - - ibid. 

sine catarrho - - - - - 63 

nigra - - - - - - 64 

Rupia - ... . . . 247 

simplex - 248 

1 prorninens ..... ibid. 

escharotica - 249 

Scabies - - - - - - -194 

papuliformis ----- 196 

lymphatica - - - - 198 

purulenta - 200 

cachectica - 203 

Scales, how produced .... 25 

Scalledshead. See Porrigo favosa. 

Scarlatina ---... 70 

simplex ------ 72 

anginosa ..... 74 

maligna - - - - - ^ 85 

Scarlet-fever. See Scarlatina. 

Scelotyrbe - - - - - -137 

Scurvy, a misapplied term - - - - 17. 296 

Shingles. See Herpes zoster. 

Small-pox. See Variola. 

probably known to the ancients - 64 



343 INDEX. 

Page. 

Spilus - 335 

Strophulus ...... j 

..... intertinctus ..... 

albidus ---... 

v confertus - - - - _ # 

volaticus ..... 5 

candidus >■ ^ 



Swine-pox. See Chicken-pox. 

Sycosis ...... 

menti ----- 301 

capillitii .... . 30t: 

Tetter, dry or scaly. See Psoriasis': 

' ' humid. See Impetigo. 
Tinea. See Porrigo. 
Thrush. See Aphtha. 
Tooth rash. See Strophulus. 

Vaccinia .-..__ o2(?- 

Vari. See Acne. 
Varicella - - - -j. . -212 



Variola 



193 



Verruca ------. 279 

Vitiligo - - - - - - 281 

Urticaria ---... 39 

— — — febrilis ..... ^ 

evanida ------ 92 

perstans - - - - . 94 

■ conferta ----.. g 5 

subcutanea ----- \f }% 

tuberosa -----_ 95 

Water-jags. See Chicken-pox. 

Wheals ---._. 39 

Wheal-worms --.-.. 20$ 

Yaws. See Framboesia. 

Zona. See Herpes. 

Zoster. See the same. 



r 



